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Rod Haywood Enterprises, Inc.

Sign Your Little Einstein Up Today!

Want to sign your little inventor up for his first step on his way to innovation? Fill out these 2 forms below and then we will finalize the process when your child comes in for his/her first trial session!

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Child's Information

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Child's First Name: *

Child's Last Name: *

Child's Middle Initial: *

E-mail address: *

Street Address: *

City: *

State: *

Zipcode: *

Home Phone Number: *

Cell Phone Number: *

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Female

What school will your child attend in the fall? *

Names of Any Siblings Attending Einstein's Kids: *

What areas specifically does your child need help with? *

Please describe any unique obstacles we may need to know about.

Does your child have allergies? If so what? *

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Parent Information Form

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First Name: *

Last Name: *

Address: *

E-mail address: *

Child's Name: *

Relation to Child: *

Work Phone:

Cell Phone: *

Home Phone:

Emergency Contact (Name, Relation to student, and Phone Number): *

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