Child's Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 1 Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Phone

(###)

###

####

Parent 2 Name

First Name

Last Name

Phone

(###)

###

####

Address

If different from Child's

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Phone

(###)

###

####

Name *

First Name

Last Name

Phone *

(###)

###

####

Please select one *

5 days

3 days

*

Instagram/Facebook

Came to Book Swap/Open house

Friend/Colleague

Received email

At an event (Brooklyn Conservatory of Music)

Please select one *

No, thanks

3:00-5:00 PM

Which days of the week do you wish to enroll your child for After School Care?

Monday

Tuesday

Wednesday

Thursday

Friday