Skip to content
(410) 461-3393
[email protected]
3030 Bethany Lane | Ellicott City, MD 211042
Search
Search
Close this search box.
Home
Classes
Staff
Community
Registration
Menu
Home
Classes
Staff
Community
Registration
Register Now
registration form
registration form
Application for Enrollment
Child's Name
Date of Birth
Child's Address
Child's Gender
Boy
Girl
First Day of Enrollment
Date of Withdrawal
Days to Attend
Mon
Tues
Wed
Thur
Fri
Departure
Hours of Arrival
The child will be released only to the person signing this application and the following emergency contact persons. (They should be listed on the emergency card.) Legal authorities will be contacted for children left at the center one-hour after closing time of the center.
Name
Address
Phone
Relationship
Email Address
Mother/Guardian Name
Phone
Home Address (if different from child's)
Employer
Office Phone
Employer Address
Father/Guardian Name
Phone
Home Address (if different from child's)
Employer
Office Phone
Employer Address
Parent's Marital Status
Married
Single
Divorced
Pediatrician's Name
Office Phone
Address
My child has the following allergies and/or special needs:
How did you learn about Bethany Learning Center?
Send
