Student Enrollment Form

Please complete the student enrollment form below. Note, a separate form will be required for each child enrolled in the program. If you have questions please contact Scarlett Roth. 

Student Information

Gender
Parent / Guardian Information
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Emergency Contact
Release to a Non-Parent

To whom may your child be released to other than a parent? Please list their name(s), relationship and phone numbers. 

Medical, Allergies & Other Information

Your signature on this form verifies that the information given is correct and that you give permission to the staff of Merry Hearts to provide the necessary care for your child either on site or at the nearest medical facility in the event of a medical emergency. In the even of such an emergency we will make every effort to reach you or your emergency contact. 

Thank you for completing the student enrollment form!