Early Learning Center Pre-Enrollment Application

Early Learning Center Pre-Enrollment Application
Date you wish to enroll your child in the Early Learning Center at the earliest*

MonthDayYear
Child's Name*

First NameMiddle NameLast NameSuffix
Expected Date of Birth*

MonthDayYear
Actual Date of Birth

MonthDayYear
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
Parent/Guardian's Full Name*

PrefixFirst NameMiddle NameLast NameSuffix
LSUHSC School*

School of MedicineAllied Health ProfessionsPublic HealthAdministrationStaffDental SchoolNeither parent works at LSUHSC
Department or Place of Employment*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Phone is:

Cell phoneLand 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?*

YesNo
Does your child have an IFSP?*

YesNo
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*

WhiteBlack or African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderMore than one raceUnrecorded
Child's Races (More than One Race)

WhiteBlack or African AmericanAmerican Indian or Alaska NativeAsianNative 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*

HispanicNot HispanicUnrecorded
Signature*
Type name in box above to sign
Status*

WaitlistContactedEnrolledReleased
Date*

MonthDayYear
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*
Should be Empty:

Early Learning Center Pre-Enrollment Application

Parent/Guardian