HDC Early Learning Center Pre-Enrollment Application

Date you wish to enroll your child in the Early Learning Center at the earliest *

Month Day Year

Child's Name *

First Name Middle Name Last Name Suffix

Expected Date of Birth *

Month Day Year

Actual Date of Birth

Month Day Year

For the expected date of birth, if the date is not known, use the first day of the month. It is not required to provide an expected date of birth if an actual date of birth is given; however, the user has the freedom to choose whether or not to provide both dates.

Parent/Guardian's Full Name *

Prefix First Name Middle Name Last Name Suffix

LSUHSC School *

School of Medicine Allied Health Professions Public Health Administration Staff Dental School Neither parent works at LSUHSC

Department or Place of Employment *

Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Phone is:

Cell phone Land line

E-mail address

example@example.com

The Early Learning Center is an inclusive program well equipped to serve children with disabilities. Does your child have an identified disability or medical condition? If yes, please describe.

Does your child have an IEP? *

Yes No

Does your child have an IFSP? *

Yes No

Does your child have any siblings who are currently enrolled? If yes, please list their names and ages.

Is your child currently receiving therapy services? If so, please list the agency name, the therapist name, and the contact information.

Primary Language Spoken at Home *

Secondary Language Spoken at Home

Primary and secondary languages cannot be the same.

Applicants who are accepted are entered into the National Information Reporting System (NIRS). NIRS uses the definitions of race and ethnicity defined by the U.S. Census Bureau and the Office of Management and Budget (OMB) in 1997.

White White refers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American refers to people having origins in any of the Black racial groups of Africa.
American Indian or Alaska Native refers to people having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Asian refers to people having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent (e.g. Asian Indian).
Native Hawaiian or Other Pacific Islander refers to people having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
More than one race includes individuals who identify with two or more racial designations.
Unrecorded is included for individuals who are unable to identify with the categories.

Child's Race *

White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander More than one race Unrecorded

Child's Races (More than One Race)

White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander

Sub-category of Asian Race

Sub-category of Pacific Race

Hispanic is an ethnic category for people whose origins are in the Spanish-speaking countries of Latin America or who identify with a Spanish-speaking culture. Individuals who are Hispanic may be of any race.

Child's Ethnicity *

Hispanic Not Hispanic Unrecorded

Signature *

Type name in box above to sign

Status *

Waitlist Contacted Enrolled Released

Date *

Month Day Year

Completion of this form does not guarantee admission. When a space becomes available at the center, the parent or guardian will be notified at which time an enrollment packet, current immunization record, emergency contact information, and a non-refundable $175.00 admissions fee will be required.

Please verify that you are human *