Bright Child Online Enrollment

Enrollment

Where Every Child Shines!

Call Us: 702-43-CHILD (432-4453)

Choose Your Learning Center Location:

Child Information:

Child's First name:	Last name:
Date of Birth:	Start date:
Chronic Medical Problems?
Major Illness or Operations?
Food or Medication Allergies?
	Check Here if You Want Lunch for this Child - $15.00 per Week

Child(ren)'s Address Information

Primary Residence Address:
City:	State: Zip Code:
Primary Telephone#:

Parent or Guardian Information

Mother's First name:	Last name:
Primary Residence Addres:
City:	State: Zip Code:
Home Telephone#:	Cell Phone#:
Employer:	phone#:
Mother's DL#:	DL Exp. Date:
Mother's SSN:
Email Address:

Father's First name:	Last name:
Primary Residence Address:
City:	State: Zip Code:
Home Telephone#:	Cell Phone#:
Employer:	phone#:
Father's DL#:	DL Exp. Date:
Father's SSN:
Email Address:

Authorized Escort Information:

Please indicate below any individuals that will be authorized to communicate on any matters on all matters related to the named child(ren) in this registration or related tuition fees:

Escort First name:	Last name:
Escort Relationship to Child:
Primary Residence Address:
City:	State: Zip Code:
Home Telephone#:	Cell Phone#: