Enrollment Form

There will be a $25, non-refundable, application fee. Check or Credit Card accepted.

 

If check, mail payment to: Milestones Learning Academy P.O. Box 181418 Fort Smith, AR 72918

If credit card, please call:
479-414-3273

 

Child Information
Child's Name *
Child's Name
Child's Birthday *
Child's Birthday
Baptist Health Western Region Employee Information
Employee Name
Employee Name
Department Phone Number
Department Phone Number
Contact Information
Mother's Name
Mother's Name
Phone Number (Cell)
Phone Number (Cell)
Phone Number (Work)
Phone Number (Work)
Father's Name
Father's Name
Phone Number (Cell)
Phone Number (Cell)
Phone Number (Work)
Phone Number (Work)
Emergency Contact
Emergency Contact
Phone Number (Cell)
Phone Number (Cell)
Phone Number (Alternative)
Phone Number (Alternative)
Service Information
Beginning Date *
Beginning Date
Expected Pick Up Time *
Expected Pick Up Time
Expected Drop Off Time *
Expected Drop Off Time

 

If unable to complete the application via website, please download the editable PDF form here. Completed forms can be emailed to info@milestonesla.com with the subject line: Application - ‘Last Name’