Fall 2020 on-site school day Click here to PAY ONLINE for the Fall 2020 programs All the fields with * are mandatory Student Name* Birthday (mm/dd/yyyy)* Gender* MF School Attending* Grade* K1st2nd3rd4th5th6th7th Parent 1 / Guardian 1 Name* Parent 1 Email* Parent 1 Home Phone / Work Phone / Cell Parent 2 / Guardian 2 Name Parent 2 Email Parent 2 Home Phone / Work Phone / Cell In case of emergency, if neither parent cannot be reached, call Emergency Contact Name 1* Phone Number* Emergency Contact Name 2 Phone Number Pick Up & Delivery Authorization (other than the parents) Name Phone Number Medical Information of the Student Family Dentist Name Family Dentist Phone Number Dentist Office Address Medical Doctor Name Doctor Phone Number Doctor Office Address Date of Last Physical Exam (mm/dd/yyyy) List known Allergies or Medical problems below. Input 'None' for no known allergies or reactions. Contact our office for additional forms, if your student has any known allergies or reactions Known Allergies(if any) Medical Reactions(if any) Days of the week attending CM4K on-site program(3 day minimum)* MondayTuesdayWednesdayThursdayFriday Anticipated start date (mm/dd/yyyy) Tell us about your child(interests, academic level, areas of focus, and your expectations)