2023-2024 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 application, application fee ($250), and materials fee ($100). Fees are due within 2 weeks of registration, payable by:
  - Check, made out to Modern Minds, send to 495 S Nova Road, Suite 103, Ormond Beach, FL, 32174 OR
  - Venmo @modernminds OR
  - Zelle to stevewaterman@modernmindslearning.com OR
  - Cash, dropped off at Modern Minds
**NOTE - This form CANNOT be printed, we can only accept online submissions.
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Last Name, First Name of Student *
Home Address - Number and Street *
City and Zip *
2023-2024 Grade Level *
Date of Birth *
MM
/
DD
/
YYYY
Primary Parent Name *
Primary Parent Email *
Primary Parent Cell  *
Secondary Parent Name
Secondary Parent Email
Secondary Parent Cell 
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.
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