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6 Meriam St, Lexington, MA 02420 | 781.862.5485 | office@lexpc.org
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Child's Name
*
Birthdate
*
Birthplace
Gender
*
Male
Female
Street Address
City, State
*
Zip
*
How did you hear about us?
*
Friend
LPC Alum
Web search
Real estate agent
Other
Parent's Name
*
Address (if different)
Number
Secondary Phone
Email
*
Occupation
Parent's Name
Address (if different)
Number
*
Single Line Text
Email
Occupation
Desired Start Date
*
Term Choice
*
10-month program
12-month program
Summer Only (July & August)
First Choice of Days
*
M/T/W/Th/F (5 days)
M/W/F (3 days)
T/Th (2 days)
Second Choice of Days
*
M/T/W/Th/F (5 days)
M/W/F (3 days)
T/Th (2 days)
First Choice of Hours
*
8-1
8-3:30
8-6
Second Choice of Hours
*
8-1
8-3:30
8-6
Early bird
Early Bird (7:30-8 am)
Early Bird (7:45-8 am)
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