Thanks for considering Smart Start Academy! To submit an enrollment application, please complete the following information:  

Choose A Program:

STUDENT INFORMATION

Student Name:
   
Nick Name:
Date of Birth:
Home Address:
City:
   State:      Zip  

ATTENDANCE OPTIONS

Will Attend On:
                                   
Will Attend From:
      To:   
If Drop-In, From:
      To:   
Meal Options:
        |         |         |         |    

PARENTS INFORMATION

Name
Home Ph.
Work Ph.
Other Ph.
Email
Required. Will also serve as parent portal username.
Name
Home Ph.
Work Ph.
Other Ph.
Email

 

NAMES OF OTHERS AUTHORIZED TO PICK-UP STUDENT

1.)  2.) 
3.)  4.) 

 

EMERGENCY INFORMATION

Hospital of Choice:    Ph. : 

EMERGENCY CONTACTS

Name
Address
Phone
Relationship
Code Word
Name
Address
Phone
Relationship
Code Word
AttendDays:
AttendHoursStart:
AttendHoursEnd:
DropInHoursStart:
DropInHoursEnd:
Meals:
I certify to the best of my knowledge that the Student / Child being registered with this submission is in good mental and physical health and able to participate in the child care program at Intelligence Refined Academy.