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WIU Bilingual Early Learning and Family Center Interest Form
(1) Parent or Guardian Name
*
First Name
Last Name
(1) Parent or Guardian Primary Email
*
example@example.com
(2) Parent or Guardian Name
First Name
Last Name
(2) Parent or Guardian Primary Email
example@example.com
Best Family Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is either parent/guardian a student at Western Illinois University?
*
Yes
No
Is either parent/guardian a student at Black Hawk College?
*
Yes
No
Home Address of Family
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Child Information
Fill out information for each child
(1) Child Name
*
First Name
Last Name
(1) Child Birthdate
*
-
Month
-
Day
Year
Date
(1) What is child's primary language?
*
English
Spanish
Other
(1) Does child speak a second language?
*
English
Spanish
No, my child does not speak another language
Other
(1) Has child been identified with a disability?
*
Yes
No
Other
Do you want to add a second child to the interest form list?
Yes
No
(2) Child Name
First Name
Last Name
(2) Child Birthdate
-
Month
-
Day
Year
Date
(2) What is child's primary language?
English
Spanish
Other
(2) Does child speak a second language?
English
Spanish
No, my child does not speak another language
Other
(2) Has child been identified with a disability?
Yes
No
Other
Do you want to add a third child to the interest form list?
Yes
No
(3) Child Name
First Name
Last Name
(3) Child Birthdate
-
Month
-
Day
Year
Date
(3) What is child's primary language?
English
Spanish
Other
(3) Does child speak a second language?
English
Spanish
No, my child does not speak another language
Other
(3) Has child been identified with a disability?
Yes
No
Other
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Next
Additional Information
Background, Income and Time-frame
Please select the ethnic background that feels most comfortable to you:
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Enter your family income:
*
Select the approximate time-frame that you would like your child to attend the WIU-Quad Cities Early Learning Lab site:
*
Monday - Friday, 7:00 a.m. - 3:00 p.m.
Monday - Friday, 3:00 p.m. - 9:00 p.m.
Saturday, 7:30 a.m. - 4:30 p.m.
Monday - Friday, 8:30 a.m. - 11:00 a.m.
I do not need regular childcare but I do need a drop in option because I am a student and need care for class times and homework.
Thank you for your interest in the WIU-Quad Cities Bilingual Early Learning Lab Site!
By completing this form, you are expressing your interest in having your child attend the WIU Quad Cities Bilingual Early learning program. This program will have a focus on play-based learning and Spanish Bilingual Language Development. We are a social justice conscious program with priority placement for families that may be experiencing marginalization. Please understand that this is an interest form, and we will contact families by phone call for placement if spots are available in the age group that you have expressed interest in, and this form does not guarantee a spot in the program.
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