Enrollment Request Title *Miss.Mrs.Ms.Mr.Rev.Dr.Name *FirstLastPhone (Daytime) *Phone (Evening) *Email *Address (Street, Apt, PO Box, etc. | County, State, Zip Code) *How did you hear about Bethel Learning Centers? *RadioTelevisionPasser-byCurrent Bethel Learning Center ParentFormer Bethel Learning Center ParentFriend/Family Member Bethel A.M.E. Church MemberBethel Learning Center WebsiteOtherI am interested in... *Child Development Center Enrollment (Ages 8 weeks to K-4)Christian Academy Enrollment (K5-5th Grade)Excel! After School Care Enrollment (Ages 5-13)Student Name *FirstLastWhat grade will your student enter upon enrollment? *Infant (8 wks - 12 mos)Toddler (12 mos - 24 mos)K-2K-3K-4K-51st2nd3rd4th5thEmailSubmit