Parent Name *

First Name

Last Name

Parent Phone Number *

(###)

###

####

Student Birthdate *

MM

DD

YYYY

Is this child potty trained? *

If the student does not need consistent reminders to use the restroom, the majority of the time and does not have consistent accidents, we consider them fully potty trained.

Si

No

We have started potty training

Semester/s of Interest *

Summer 2023

Fall 2023

Spring 2024

Summer 2024

Fall 2024