First and Last Name of Student *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Caregiver #1 *

First Name

Last Name

Address (if different than student's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Name of Caregiver #2

First Name

Last Name

Address (if different than student's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Please select Assist vs. Non-Assist *

*Important Notes: Please see our website (www.dextercoop.com/tuition) to view current tuition rates for assist and non-assist roles. These tuition rates are subject to change. 3s assist parents can expect to assist 1-2 times per month during their child’s class time, and 4s assist parents can expect to assist 2-3 times per month during their child’s class time. Non-Assist spots are limited to 2 spots per class (based on a full class).

Assist

Non-Assist

Please Select First Preference Class (3AM, 3PM, 4AM, 4PM): *

3AM

3PM

4AM

4PM

Would you be interested in the opposite class, should your first preference be full? (ie: 3PM, if selecting 3AM for first preference) *

Yes

No

Are you interested in sibling care?

Yes

No

Maybe