Early Childhood Enrollment Inquiry

Great Start Readiness Program Enrollment Inquiry

This form is for enrollment of

Student Information

Student First Name

Student Middle Name

Student Last Name

Home Address Line 1

Home Address Line 2

City

State

Zip

Date of Birth

Student Gender (required) Male Female

Program Information

Which Program do you wish to enroll your child in

Has your child/children ever attended Martin Luther King, Jr Education Center Academy? (required) Yes No

If yes, please provide information about student and when when attended

Parent/Guardian Information

Parent/Guardian Name

Parent/Guardian Email

Parent/Guardian Contact (Cell/Home)

Last School Attended

Do you have access to the internet? (required) Yes No Other

If Other please explain

Do you have access to an electronic device? (Laptop, tablet, desktop, cellular phone, etc...) (required) Yes No

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