New Enrollment Applications — Milestones Learning Academy

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

First Name

Last Name

Child's Birthday

YYYY

Gender

Will other siblings be applying?

If yes, please include name and ages:

Baptist Health Western Region Employee Information

Employee Name

First Name

Last Name

Employee Number

Department at Baptist Health

Department Phone Number

(###)

###

####

Contact Information

Mother's Name

First Name

Last Name

Phone Number (Cell)

(###)

###

####

Phone Number (Work)

(###)

###

####

Father's Name

First Name

Last Name

Phone Number (Cell)

(###)

###

####

Phone Number (Work)

(###)

###

####

Emergency Contact

First Name

Last Name

Phone Number (Cell)

(###)

###

####

Phone Number (Alternative)

(###)

###

####

Service Information

Beginning Date

YYYY

Expected Pick Up Time

Hour

Minute

Second

Expected Drop Off Time

Hour

Minute

Second

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’

Download PDF