Enrollment Application
*Print and mail to address below or fax to 253-1639*
Thank you so much for your interest in Brookfield Academy. Selecting a childcare provider can be
challenging and one of the most important decisions you will make for your young child. Brookfield
Academy will have a well-rounded environment to enhance the academic, social, and spiritual
growth of your child in a facility specifically designed for children.
A $50.00 non-refundable application fee is due upon submission of application. Upon
acceptance, and before your child will be able to attend Brookfield Academy, we will need you to fill
out a more detailed registration form, turn in all health records, and read and sign our contract. If
you a spot becomes available before you need care, half-price tuition will be due weekly to hold
the spot. If you have any questions, please call 253-1329.
Today’s Date: _______________________ Date Needed: ___________________
Child’s Name: __________________________________________________________
Address: _______________________________________________________________
City: ___________________ State__________ Zip__________
Home Phone: __________________
DOB: ________________ Age: __________ Sex: _________
Is child currently enrolled in another center? Yes___ No___
If yes, where? ___________________________________________________________
Are there siblings at home? Yes ____ No ___ If yes, their ages _____________________
Comments or Special Instructions: _________________________________
________________________________________________________________________
________________________________________________________________________
Is He or She Potty Trained? ___________
TYPE OF CARE NEEDED
Full-time childcare
Before-school After-school
Name of school __________________________________________
School’s Out Program Summer/Holiday Camp
Mom’s Name: ________________________________ Cell phone # ________________
Mom's Place of Employment: _____________________ Work phone # _______________
Dad’s Name: ______________________________ Cell phone # ________________
Dad's Place of Employment: _______________________ Work phone # _______________
Parent child resides with _______________________________________________
Name of step-parent, if one at home_____________________________________
*E-mail: ____________________________________________ Mom’s Dad’s
Parent’s Signature _____________________________________________________
For Office Use Only
Deposit Amount: ___________ Date Received: ____________ Ck#_______
Room ________________________ Date Child Will Attend ___________
*Print and mail to address below or fax to 253-1639*
Thank you so much for your interest in Brookfield Academy. Selecting a childcare provider can be
challenging and one of the most important decisions you will make for your young child. Brookfield
Academy will have a well-rounded environment to enhance the academic, social, and spiritual
growth of your child in a facility specifically designed for children.
A $50.00 non-refundable application fee is due upon submission of application. Upon
acceptance, and before your child will be able to attend Brookfield Academy, we will need you to fill
out a more detailed registration form, turn in all health records, and read and sign our contract. If
you a spot becomes available before you need care, half-price tuition will be due weekly to hold
the spot. If you have any questions, please call 253-1329.
Today’s Date: _______________________ Date Needed: ___________________
Child’s Name: __________________________________________________________
Address: _______________________________________________________________
City: ___________________ State__________ Zip__________
Home Phone: __________________
DOB: ________________ Age: __________ Sex: _________
Is child currently enrolled in another center? Yes___ No___
If yes, where? ___________________________________________________________
Are there siblings at home? Yes ____ No ___ If yes, their ages _____________________
Comments or Special Instructions: _________________________________
________________________________________________________________________
________________________________________________________________________
Is He or She Potty Trained? ___________
TYPE OF CARE NEEDED
Full-time childcare
Before-school After-school
Name of school __________________________________________
School’s Out Program Summer/Holiday Camp
Mom’s Name: ________________________________ Cell phone # ________________
Mom's Place of Employment: _____________________ Work phone # _______________
Dad’s Name: ______________________________ Cell phone # ________________
Dad's Place of Employment: _______________________ Work phone # _______________
Parent child resides with _______________________________________________
Name of step-parent, if one at home_____________________________________
*E-mail: ____________________________________________ Mom’s Dad’s
Parent’s Signature _____________________________________________________
For Office Use Only
Deposit Amount: ___________ Date Received: ____________ Ck#_______
Room ________________________ Date Child Will Attend ___________
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| Brookfield Academy An Early Learning Center |