NMCSC Charger KidZone (CKZ)
Enrollment Form

How many children do you wish to enroll? *

School Year *

2024-2025 (Next School Year)

Child #1

First Name *

MI *

Last Name *

Date of Birth * 🛈 +

School *

Grade Level *

Teacher (if known)

Bus Number (if known)

Who has legal custody of this child?

(Please remember to provide a copy of any custody agreement/decree - if applicable)

*

Both Parents	Mother Only
Father Only	Other Other

Schedule

+ Child's first day at CKZ

First day of school year or enter other start date

*

+ Child's last day at CKZ

Last day of school year or enter other end date

*

Select Weekly Tuition Schedule

(see Parent Handbook for information on monthly tuition plans)

*

Full Time 4-5 days/week

Part Time 1-3 days/week

Days of the Week *

Medical Information

Primary Physician Name

Primary Physician Phone

Dentist Name

Dentist Phone

Does your student have any of the following?
(Check all that apply)

Please explain any of the above

Are there any modifications or accommodations that would be beneficial to your child? *

Yes

No

Child #2

First Name

MI

Last Name

Date of Birth 🛈 +

School

Grade Level

Teacher (if known)

Bus Number (if known)

Who has legal custody of this child?

(Please remember to provide a copy of any custody agreement/decree - if applicable)

Both Parents	Mother Only
Father Only	Other Other

Schedule

+ Child's first day at CKZ

First day of school year or enter other start date

+ Child's last day at CKZ

Last day of school year or enter other end date

Select Weekly Tuition Schedule

(see Parent Handbook for information on monthly tuition plans)

Full Time 4-5 days/week

Part Time 1-3 days/week

Days of the Week

Medical Information

Primary Physician Name

Primary Physician Phone

Dentist Name

Dentist Phone

Does your student have any of the following?
(Check all that apply)

Please explain any of the above

Are there any modifications or accommodations that would be beneficial to your child?

Yes

No

Child #3

First Name

MI

Last Name

Date of Birth 🛈 +

School

Grade Level

Teacher (if known)

Bus Number (if known)

Who has legal custody of this child?

(Please remember to provide a copy of any custody agreement/decree - if applicable)

Both Parents	Mother Only
Father Only	Other Other

Schedule

+ Child's first day at CKZ

First day of school year or enter other start date

+ Child's last day at CKZ

Last day of school year or enter other end date

Select Weekly Tuition Schedule

(see Parent Handbook for information on monthly tuition plans)

Full Time 4-5 days/week

Part Time 1-3 days/week

Days of the Week

Medical Information

Primary Physician Name

Primary Physician Phone

Dentist Name

Dentist Phone

Does your student have any of the following?
(Check all that apply)

Please explain any of the above

Are there any modifications or accommodations that would be beneficial to your child?

Yes

No

Child #4

First Name

MI

Last Name

Date of Birth 🛈 +

School

Grade Level

Teacher (if known)

Bus Number (if known)

Who has legal custody of this child?

(Please remember to provide a copy of any custody agreement/decree - if applicable)

Both Parents	Mother Only
Father Only	Other Other

Schedule

+ Child's first day at CKZ

First day of school year or enter other start date

+ Child's last day at CKZ

Last day of school year or enter other end date

Select Weekly Tuition Schedule

(see Parent Handbook for information on monthly tuition plans)

Full Time 4-5 days/week

Part Time 1-3 days/week

Days of the Week

Medical Information

Primary Physician Name

Primary Physician Phone

Dentist Name

Dentist Phone

Does your student have any of the following?
(Check all that apply)

Please explain any of the above

Are there any modifications or accommodations that would be beneficial to your child?

Yes

No

Parent/Guardian #1

Relationship To Child *

First Name *

Last Name *

Email Address *

Street Address *

City *

State *

List Other State *

Zip Code *

Cell Phone *

Home Phone

Work Phone

Check all that apply *

Lives with Child

Emergency Contact and Authorized to Pick-Up

Responsible for Payment

Employee of NMCSC *

Yes

No

Building *

Parent/Guardian #2

Relationship To Child

First Name

Last Name

Email Address

Street Address

City

State

List Other State

Zip Code

Cell Phone

Home Phone

Work Phone

Check all that apply

Lives with Child

Emergency Contact and Authorized to Pick-Up

Responsible for Payment

Employee of NMCSC

Yes

No

Building

Additional Emergency Contacts & Authorized Pick-Up

Please note for authorized pick-up: must be 18 years or older and ID required!

	Contact #1	Contact #2	Contact #3
Name	Contact #1	Contact #2	Contact #3
Relationship to child	Contact #1	Contact #2	Contact #3
Cell Phone	Contact #1	Contact #2	Contact #3

Monday	Tuesday
Wednesday	Thursday
Friday

Monday	Tuesday
Wednesday	Thursday
Friday

Monday	Tuesday
Wednesday	Thursday
Friday

Monday	Tuesday
Wednesday	Thursday
Friday

NMCSC Charger KidZone (CKZ) Enrollment Form

Child #1

Schedule

Medical Information

Child #2

Schedule

Medical Information

Child #3

Schedule

Medical Information

Child #4

Schedule

Medical Information

Parent/Guardian #1

Parent/Guardian #2

Additional Emergency Contacts & Authorized Pick-Up

NMCSC Charger KidZone (CKZ)
Enrollment Form