Register | Melting Pot Healing

Afterschool Care Application

Please fill out this form to enroll in afterschool care. Please Fill in N/A for blank answers.

Parent/Guardian First name

Parent/Guardian Last name

Phone number

Child or List Multiple Child's Name

Child Date of birth

Month

Day

Year

If you are enrolling multiple children please list the dates of birth by their name in field above.

Please List allergies/any mental disabilities

Type Parent/Guardian Name

I authorize Media Authorization to Melting Pot Healing Center

I agree to the Melting Pot Healing Center's terms and conditions.