Becker Admissions Application

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Child Information

* First Name

* Last Name

* Date of Birth (mm/dd/yyyy)

* Male/Female

* Current School

* Street Address

* City

* State

* Zip

Parent 1 Information

* Parent 1 First Name

* Parent 1 Last Name

* Parent 1 Email

Address (if different)

City

State

Zip

* Cell Phone

(###-###-####)

* Home Phone

(###-###-####)

Employer

Parent 2 Information

Parent 2 First Name

Parent 2 Last Name

Parent 2 Email

Address (if different)

City

State

Zip

* Cell Phone

(###-###-####)

Home Phone (if different)

(###-###-####)

Employer

Applicant Information

* How did you hear about Becker?

* Applicant is a: (select all that apply)

* Class Preferred (please select)

For Young Toddlers Class (9:00 a.m.-12:30 p.m. or 9:00 a.m.-2:30 p.m.)

For TWOS (9:00 a.m. - 12:30 p.m. or 9:00 a.m. - 2:30 p.m.)

For THREES (9:00 a.m. - 12:30 p.m. or 9:00 a.m. - 2:30 p.m.)

For PreK (9:00 a.m. - 2:30 p.m.)

For Kindergarten (9:00 a.m. - 2:30 p.m.)

Early Care or Extended Care (select all that apply)

Early Care (7:45 a.m. - 9:00 a.m.)Extended Care (2:30 p.m. - 5:30 p.m.)

* Acknowledgment of Fee ($25)

Acknowledgment of Fee ($25)

Total:

Tue, October 28 2025 6 Cheshvan 5786

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