Annie's Place Enrollment Application

Enrollment Application

Annie's Place at Parkland is a collaboration between Parkland hospital and Annie's Place, a Dallas area nonprofit, to provide free drop-in childcare for families in health crisis.
Director: Diana Aviles

Assistant Directors: Leonela Garcia

2131 Butler Street
Dallas, TX 75235
Tel: 214-266-8064 Fax: 214-266-8083
Email: Welcomedesk@anniesplacecares.org

Website: www.anniesplacecares.org
This is the first time I am applying to Annie's Place:*

YesNoOther
I was referred to Annie's Place by:*

My Parkland Provider/ClinicOther Provider/ClinicFriend/FamilyParkland EmployeeOther
First time I need childcare

MonthDayYear
DateHourMinutesAM/PM Option
Parkland Email*
example@example.com
What department do you work in? *

Applicant Information

Parent/Legal Guardian of the children needing care.
Parent/Legal Guardian #1*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Email*
example@example.com
Home Phone
Cell Phone *
Address *

Street Address

Street Address Line 2

CityState

Zip Code
Race: Parent/Legal Guardian #1*
Preferred Language: Parent/Legal Guardian #1 *
Form of Identification: Parent/Legal Guardian #1*

Driver's LicenseState ID/ Real IDMilitary IDCertificate of Naturalization/CitizenshipU.S. PassportEnhanced Tribal CardsOther
Form of Identification ID Number: Parent Legal Guardian #1*
The number on the chosen form of identification listed above
Is there another parent/legal guardian?*

YesNo
Parent/Legal Guardian #2*

First NameLast Name
Gender*

MaleFemaleNon-BinaryOther
Cell Phone *
Home Phone
Work Phone
Email Address
Parent/Legal Guardian #2 has the same address as #1*

YesNo
Address: Parent/Legal Guardian #2 *

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Language: Parent/Legal Guardian #2*
Form of Identification: Parent/Legal Guardian #2*

Driver's LicenseState ID/ Real IDMilitary IDCertificate of Naturalization/CitizenshipU.S. PassportEnhanced Tribal CardsOther
Form of Identification ID Number: Parent Legal Guardian #2*
The number on the chosen form of identification listed above

Enrollment Application