Enrollment Form

Your child first name

Your child last name

Child's date of birth

Child's grade level

Child's Current School

Does your child require any special accommodations?

Describe your child's personal interests, academic strengths and challenges.

Allergies and special diets

Medical or medication needs

Name of primary care provider

Phone number of primary care provider

Health insurance provider and policy #

By checking this box, I give permission for trained Wellbright staff to provide basic first aid or CPR to my child if needed. I understand that Wellbright will make every reasonable effort to contact me or my emergency contact if my child requires medical attention.If I cannot be reached and delaying care could put my child’s health at risk, I authorize Wellbright to: transport my child to a medical facility, and obtain necessary emergency medical treatment.

Preferred Enrollment Plan

Preferred Payment Plan

1 time payment 10 installments payment

Do you plan to use HOPE scholarship

Does your family need financial aid?

Do you need Before or After school program

What location do you prefer ?

Martinsburg Berkeley Springs Jefferson County (exact location is TBD)

# 1 Parent/guardian first name

Parent/guardian last name

Relationship to the child

Occupation

Phone

Home address

# 2 Parent/guardian first name

Parent/guardian last name

Relationship to the child

Occupation

Phone

Home address

# 1 Emergency Contact - First name

Last name

Relationship to the child

Cell phone

#2 Emergency Contact -First name

Last name

Relationship to the child

Cell phone

Names of people who are authorized to pick up your child

MISSION STATEMENT

HOURS OF OPERATION

ENROLLMENT TERMINATION, WITHDRAWAL, AND TUITION POLICY

CONSENT FOR OBSERVATION OF STUDENTS

MEDIA RELEASE

This consent is voluntary.

I agree I opt out

PARENT AUTHORIZATION AND LIABILITY AGREEMENT

AGREEMENT

I agree

Date

Wellbright Enrollment Form