Registration Form

Mother's Details

Mother's Name Last, First

Mother's Home Phone Phone Format: xxx-xxx-xxxx

Mother's Mobile Phone Phone Format: xxx-xxx-xxxx

Mother's Work Phone Phone Format: xxx-xxx-xxxx

Mother's Email

Street Address

City

State

Zip

Father's Details

Father's Name Last, First

Father's Mobile Phone Phone Format: xxx-xxx-xxxx

Father's Work Phone Phone Format: xxx-xxx-xxxx

Father's Email

Check if Father's address is different from above

Father's Home Phone Phone Format: xxx-xxx-xxxx

Father's Street Address

City

State

Zip

Emergency Contact

Name Last, First

Relationship to Child (Grandparent, Aunt, Uncle, Family Friend, etc.)

Primary Phone Phone Format: xxx-xxx-xxxx

Secondary Phone Phone Format: xxx-xxx-xxxx

Email Address

Child Information

Name Last, First

Student Status

Date of Birth MM-DD-YY

Grade Select One

Child's health, educational, or behavioral needs?
Please list any allergies

+ Add another child

Medical Information

Please provide your children's medical information in case of an emergency. (Optional)

Physician's Name

Physicians Number

Insurance Company Name

Policy Number

Physicians Street Address

City

State

Zip

Payment Options

Online using the link provided by DOL
By check, sent via mail
By check or cash on campus
By financial aid application

Please Note: Financial aid applications may take up to 2 weeks for review

I am requesting:

A Payment Plan

Number of Payments:

Amount per payment: $

Paid in full by: MM-DD-YY

A Scholarship

In the amount of $

I will be paying for the Program Tuition:

Online using the link provided by DOL
By check, sent via mail
By check or cash on campus
Using charter funds, I am requesting DOL to match me with a charter.
Using charter funds from a Charter School.(I am registered with the charter school listed below)

Paying for tuition and fees online requires an additional 4% convenience fee.
To avoid this fee, you may pay by mail

Please make checks payable to “DOL.” Mail to DOL at 417 Associated Rd. #272, Brea, CA 92821

If you have a promo code, please enter it here:

Program Tuition Agreement

By checking the boxes below, you are agreeing to the terms. In order to complete the registration, you must agree to the following:

I agree to the Terms and Conditions
I agree to the Liability Agreement
I agree to the Parent support, policies, and procedures

Your Signature

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