Learning Adventures for Preschoolers
Parent & Child application
Child's General Info
Child's Name:
*
First Name
Last Name
Child's date of birth?
*
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Month
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Day
Year
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Gender:
Female
Male
Other
Home Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does your child attend preschool?
*
Yes
No
Other
Other
Name of preschool:
Parent's Information
Parent's/Guardian's name
*
Mobile number
*
Secondary Mobile Number
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Area Code
Phone Number
Home Number
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Area Code
Phone Number
Email address
*
Emergency Contact
Full name:
First Name
Last Name
Primary phone number
Secondary phone number
Medical/Health Info
Please feel free to list any illness or health conditions or concerns you'd like us to be aware of:
Medications, allergies, special needs etc.
Package
Our service is targeted for children ages 3 to 6 years old.
What service are you looking for?
Outdoor adventure
In-home adventure
Online Role Play - group class (30 min)
1-on-1 Online adventure (45 min)
Other
Service Request
Your start date:
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Month
-
Day
Year
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What time are you requesting your play date?
Our hours are 9:00 am to 5:00 pm
Day(s) of the week you are requesting?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Other
Child Description
Please tell us more about your child.
Energy, attention span, and personality; anything to help us connect best with him or her.
Please list some things your child loves to do.
What are his/her strengths?
Is this simply for enrichment? Or do you wish to see improvement in a particular subject area?
(alphabet, numbers, language, geography)
Household Description
Briefly describe your child's daily schedule and your parent home/work lifestyle.
How did you hear about backpack kids?
Thank you for choosing backpack kids!
Do we have your permission to photograph or record our play dates with your child? Please specify “yes” or “no” or any other details.
Signature
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