Early Childhood Engagement Center at Temple Emanuel Application

Early Childhood Engagement Center at Temple Emanuel Application
Application Fee: $50.00

Materials Fee (For once enrolled): $75.00(If paying by check, make checks payable to Temple Emanuel)

The Early Childhood Engagement Center admits students without regard torace, creed, color, disability, gender, or national origin.
Select a Tuition plan

Tuition payments are due by the fifth of each month.Payment in full is required for the entire term enrolled whether or not thechild registered is present including inclement weather considerations.
Tuition Plan (Half Day- 8:30am-1:00pm)
Tuition Plan (Full Day- 8:00am-3:30pm)
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Siblings and Ages
Parent/Guardian Information
Parent/Guardian 1 Name*

First NameLast Name
Parent/Guardian 1 Email*
example@example.com
Parent/Guardian 1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 1 Phone Number*
Please enter a valid phone number.
Where Parent/Guardian 1 Employed
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Email
example@example.com
Parent/Guardian 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2 Phone Number
Please enter a valid phone number.
Where Parent/Guardian 2 Employed
In case of emergency, who will be notified? Please answer the fields below:
Emergency Contact Person*

First NameLast Name
Emergency Phone Number*
Please enter a valid phone number.
Emergency Contact Email*
example@example.com
Child's Allergies*
Family Physician*
Name and phone number of physician
Medical History*
Any additional medical needs we need to be aware of
Immunization*

In light of the recent rise in measles, in order to protect all of our children, we are requiring that all children have received their MMR shot. Please attain a copy of your child’s immunization records so that we can have a copy on file.
Cancelof
Agreement

Please digitally sign the agreement below
I wish to enroll my child in the program I have indicated and I agree to schedule tuition payments in full and additional fees accordingly. I agree that Early Childhood Engagement Center operators may administer or seek immediate emergency care in urgent situations.
Parent/Guardian Signature

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Date Signed

MonthDayYear
Date
*
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Application Fee
$50.00

Total

$0.00
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
Should be Empty:

Early Childhood Engagement Center at Temple Emanuel Application

Select a Tuition plan

Parent/Guardian Information

Agreement