2022-2023 MML Student Enrollment
Please fill out each question. All questions that are required have an asterisk.
*NOTE - A child's spot is not guaranteed at Modern Minds until we have received the enrollment form, enrollment fee ($200), and materials fee ($50). Fees are due within 2 weeks of registration, payable by:
  - Pay by check, made out to Modern Minds, send to 495 S Nova Road, Suite 103, Ormond Beach, FL, 32174 OR
  - Venmo @modernminds
  - Pay by cash, dropped off at Modern Minds
**NOTE - This form CANNOT be printed, we can only accept online submissions.
Sign in to Google to save your progress. Learn more
Last Name, First Name of Student *
Home Address - Number and Street *
City and Zip *
2022-2023 Grade Level *
Date of Birth *
MM
/
DD
/
YYYY
Parent One Name *
Parent One Email *
Parent One Cell Number *
Parent Two Name *
Parent Two Email *
Parent Two Cell Number *
Student Lives With:
Alternate Emergency Contact *
In case we can't get hold of you in the event of an emergency, please enter the next person to contact and their phone number.
Alternate Pickup/Dropoff Contacts *
Please list below the full names and phone numbers of any relative or friend that you give permission to pickup your child.
Medical Information *
Please list below any Health Concerns or Medications that staff should be aware of regarding your child. Please include an allergies, treatments, medications, or other pertinent medical information.
Physician Name *
Physician Phone *
Health Insurance Carrier *
Health Insurance Policy # *
Emergency Treatment: Do you authorize us to contact paramedics in the event of a medical emergency? *
Required
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms