enrollment form

Please print out and send to:

ROUND TABLE - Kids Enrichment Plus
1923 Springfield Ave.
Maplewood, NJ 07040

or fax to 973.763.6316

Or e-mail info to info@roundtablekids.com and we'll confirm payment by phone.

Name of child ____________________________ Grade ___________________

Birthday ________________________________

Address _________________________________

Town ___________________Zip ______________

School ____________________________________

Parent/caregiver main contact _______________________________________

Home phone _________________________ Work _________________________

Cell phone _________________________ - please asterisk contact preference

Email _________________________

Emergency contact & cell phone during class time (other than person above) _________________________ _________________________

Enrichment class of choice & grade level _________________________

day/time _________________________

alternate choice & grade level: _________________________

day/time _________________________

Plus, indicate private program(s) of interest and specify type

_________________________

_________________________

total cost as quoted* _________________________

*Contact us to create a schedule with our staff.

Transportation request(s) _________________________

Allergies _________________________

Payment information

check # _________________________

Credit card # _________________________

_____ MC _____ Visa _____ Amex

Exp date _________________________

Name on card _________________________

Signature _________________________