A Child's Place
2023-2024 Fives Application
Hillspoint Road, Westport, CT 06880
Child's Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Child's Home Address
Town
State
Zip
Primary Contact/Guardian Name
First Name
Last Name
Primary Contact/Guardian Role
Please Select
Mother
Father
Other
Primary Contact/Guardian Email 1
example@example.com
Primary Contact/Guardian Phone 1
Primary Contact/Guardian PhoneType
Please Select
Home
Cell
Other
Secondary Contact/Guardian Name
First Name
Last Name
Secondary Contact/Guardian Role
Please Select
Mother
Father
Other
Secondary Contact/Guardian Email 2
example@example.com
Secondary Contact/Guardian Phone 2
Secondary Contact/Guardian Phone Type
Please Select
Home
Cell
Other
Fives Program - 5 years by 12/31/23
FIVE PART DAYS (8:30 - 2:30)
FIVE FULL DAYS (7:15 - 6:00)
EXTENDED PLAY FOR PART DAY CHILDREN (2:30 - 4:30)
Desired Extended Play Day(s)
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
Status of Applicant
Currently Enrolled October 11, 2022
Switching Programs or Staff Child(ren) October 14, 2022
Sibling of Currently Enrolled Child(ren) October 14, 2022
Alumni October 18, 2022
Summer Alumni & 22-23 Waitlist Children October 21, 2022
Community applicant October 24, 2022
Check here if interested in financial aid.
A Child’s Place has discussed with me their discipline and behavior management. I received a written copy of these policies. The policy is also available at https://www.a-childs-place.org/discipline.html.
Signature
Clear
Date
/
Month
/
Day
Year
Date
A NON-REFUNDABLE APPLICATION FEE OF $75 MUST ACCOMPANY THIS APPLICATION. You will automatically be directed to our website payment page after you submit the application for your convenience.
There is a 2.75% credit card fee. ACH (direct payment) is free.
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