Westgate Child Center
Student Waitlist Registration Form
Student Information
Student Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
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12
13
14
15
16
17
18
19
20
21
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25
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29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
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2000
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
Please Select
Female
Male
Other
Program
*
Before/After School
Half Day
Full Day
Desired Start Date
*
-
Month
-
Day
Year
Date Picker Icon
Residence Information
Please provide the student's current home address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Parent/ Guardian Information
Name
*
First Name
Last Name
Primary Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Is parent's address same as student's?
*
Yes
No
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Employer
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If there is any other information about your child that you think would be useful to share, please specify.
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Application Fee
My Products
*
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( X )
Wait list application fee
$75 per child
$
75.00
Quantity
1
2
3
4
5
6
7
8
9
10
Wait list application (discounted) fee for second student
NOTE: Only select this option if this is an application for a second student in your family, to receive the multi-student discount.
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
Once you've submitted your payment, please click the submit button below to complete the application process.
Payment Methods
Choose from one of the PayPal options to
make your payment.
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