Skip to content

(410) 461-3393
[email protected]
3030 Bethany Lane | Ellicott City, MD 211042

Search

Home
Classes
Staff
Community
Registration

Home
Classes
Staff
Community
Registration

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?