24-25 ACP FIVES Application

2024-2025

A Child's Place Fives Application
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Date*

MonthDayYear
Date
WAITLIST AS OF NOVEMBER 9, 2023
Status of Applicant and Due Date

Currently Enrolled -- October 13, 2023Sibling of Currently Enrolled -- October 16, 2023Children's Community Development Center Families -- October 18, 2023Community applicant -- October 20, 2023
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact/Guardian Information

First Point of Contact
Primary Contact/Guardian Name

First NameLast Name
Phone 1
Phone Type 1
Email 1
example@example.com
Relationship to child
Secondary Contact/Guardian Information

If First Contact cannot be reached
Secondary Contact/Guardian Name

First NameLast Name
Phone
Phone
Email 2
example@example.com
Relationship to child
Fives Program - 5 years by 12/31/24*

FIVE PART DAYS (8:30 - 2:30) - Waitlist onlyFIVE FULL DAYS (7:15 - 6:00) - Waitlist OnlyEXTENDED PLAY FOR PART DAY CHILDREN (2:30 - 4:30)
Desired Extended Play Day(s):

MONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAY
Date*

MonthDayYear
Date
A NON-REFUNDABLE FEE OF $50 MUST BE RECEIVED FOR THIS APPLICATION TO BE PROCESSED (ACCEPTED AND WAITLISTED)

Payment can be made by check or online at https://securepayment.link/achildsplace/
Signature

Clear
Should be Empty:

Primary Contact/Guardian Information