Little Einstein Education Centre - Visit and Enrollment Form

Visit and Enrollment Form

Date *

Child's Name *

Childs D.O.B *

Parent Name *

Cell # *

Address *

Postal code *

Start Date *

Classroom *

Days Required *

M

T

W

TH

F

Email *

Parent Handbook Sent? *

Yes

No

How Did You Hear About Us?

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Individual Support or Accommodation

Please state medical diagnosis and treatment as well as any individual program plan and agencies involved.

Please check from the options below *

Behavioural Needs

ADHD

Autism

Cerebral Palsy

Developmental Delays

Hearing Impairment

Paraplegia

Physical Limitations

Other

If other, please provide details below...

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