Child Enrollment Form
Child's Full Name
*
First Name
Last Name
Child Date of Birth
*
-
Month
-
Day
Year
Date
Child's Gender
*
Male
Female
Name of school child attends OR N/A for daycare enrollment
*
What Services interested in:
*
After School Camp
Summer Camp
Daycare
Mentoring
Tutoring
Counseling
Other
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Family Information
Parent 1
Parent Name
*
First Name
Last Name
Home Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent 2
Parent Name
First Name
Last Name
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other children in family
Additional siblings looking to attend center
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Additional Information
Subsidize assistance (ELC)
*
Yes
No
Date Lookng to start
-
Month
-
Day
Year
Date
Gross Monthly Family Income (If seeking scholarship for after school program ).
$
Incarcerated Parent Info (If seeking scholarship for afterschool program)
First Name
Last Name
Department of Corrections #
State
Please tell us a little about your awesome child(ren)
Submit
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