Rhymes & Reasons or Kids Connect Application for Enrollment

Rhymes & Reasons: 687 Larch Avenue, Teaneck, New Jersey 07666

Kids Connect: 2 Changebridge Road, Unit G, Montville, New Jersey 07045

Child

Please use the child's full name (example: use Joseph not Joe)

First name *

Middle names

Last name *

Gender *

Male

Female

Date of birth * +

Parent or legal guardian

Title * 🛈

First name *

Last name *

Relationship to child *

Enter telephone numbers as 10 digits with no other characters

Primary phone number *

Primary phone type *

Street address *

Address line 2

City *

State *

Zip Code *

Email address *

Second parent or legal guardian

Title 🛈

First name

Last name

Relationship to child

Enter telephone numbers as 10 digits with no other characters

Primary phone number

Primary phone type

Email address

Program selection

Location *

Rhymes & Reasons

Kids Connect

Start date * +

Arrival time *

Pick up time *

Days per week *

Credit card

Name on card

Card number

CVV

Card

Expiration month

Year

Billing address

I authorize Rhymes & Reasons to charge my credit card $125.00 for the application fee.

Parent or legal guardian signature

Please enter your full name which serves as your electronic signature.

Signature *

Signature date * +

Signature

Signature date +