Waiting List — SPLASH Day School

Enrollment Submission

Terms of Agreement

SPLASH is a Christian faith-based program.

SPLASH is a private pay or Self-Arranged POC facility.
Completing this form puts my child(ren) on a waiting list and I will be contacted if space becomes available.

I have read and understand the Terms of Agreement.

Name

First Name

Last Name

Email

Phone

(###)

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Alternate Phone

(###)

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Child's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Second Child's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Start Date Desired

MM

DD

YYYY

How did you hear about SPLASH?

Family or Friend

Social Media

Search Engine

Other

Questions or Comments

Electronic Signature

Today's Date

MM

DD

YYYY