Online Enrollment Form

To submit an enrollment application, please complete the following information:



 

Choose A Program:

STUDENT INFORMATION

Student Name:
Nick Name:
Date of Birth:
Home Address:
City:
State: Zip

ATTENDANCE OPTIONS

Will Attend On:
  |     |     |     |   Fri   |     |  
Will Attend From:
       To:
If Drop-In, From:
       To:
Meal Options:
  |     |   Lunch   |     |  

PARENTS INFORMATION

Name
Home Ph.
Work Ph.
Other Ph.
Email
Required. Will also serve as parent portal username.
Name
Home Ph.
Work Ph.
Other Ph.
Email

NAMES OF OTHERS AUTHORIZED TO PICK-UP STUDENT

1.) 2.)
3.) 4.)

EMERGENCY INFORMATION

Hospital of Choice: Ph. :

EMERGENCY CONTACTS

Name
Address
Phone
Relationship
Code Word
Name
Address
Phone
Relationship
Code Word
   
AttendDays:
AttendHoursStart:
AttendHoursEnd:
DropInHoursStart:
DropInHoursEnd:
Meals:
I certify to the best of my knowledge (childs name) is in good mental and physical health and able to participate in the child care program at Intelligence Refined Academy.

 



(803) 865-6945     Fax: (803) 865-6946
rhameen@IntelligenceRefinedAcademy.com



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9354 Two Notch Rd., Columbia, SC 29223 Phone 865-6945 Fax 865-6946     Terms of Use     |     Privacy Policy

In compliance with Federal Law, IRA administers all education programs, employment activities and admissions without discrimination against any person on the basis of gender, race, color, religion, national origin, age or disability.