Pre-Registration Form

We’re so excited to hear from you. Please fill out this pre-registration form so that we can learn more about you and your children’s needs. Please note in the comments section if you’re interested in learning about a specific program or extracurricular activity. We will contact you as soon as we receive the form.

Date of Registration*
MM slash DD slash YYYY
Requested First Day of Attendance*
MM slash DD slash YYYY
Child’s Information
Child's Name*
Date of Birth*
MM slash DD slash YYYY
Sex*
- Male
- Female
Parent/Guardian Information
Parent/Guardian Name*
Marital Status*
Address*
Address City State / Province / Region ZIP / Postal Code
Phone Number*
Cell Number*
Emergency/Work Information
Employer*
Work Hours*

: Hours

Minutes

AM/PM
Address
Work Address City State / Province / Region ZIP / Postal Code
Program/Extracurricular Activities Interest(s):*
Name
This field is for validation purposes and should be left unchanged.

IMPORTANT NOTE :
One of our administrators will reach out to you ASAP to chat with you personally and discuss next steps. Also, please feel free to call us directly at 804.293.4133. Prior to your child’s attendance at Midlothian Kids Academy, additional enrollment information bust be completed, signed and returned to the MKA office along with your child’s non-refundable registration/curriculum fee

Pre-Registration Form

Child’s Information

Parent/Guardian Information

Emergency/Work Information