2024 Annie's Place Enrollment Application

Director: Diana Aviles

Assistant Director: Leonela Garcia

Annie's Place Childcare Center

2131 Butler Street
Dallas, TX 75235
Tel: 214-866-8064 Fax:214-266-8083

Email: Welcomedesk@anniesplacecares.org

Website:www.anniesplacecares.org/anniesplace
2024 Enrollment Application

Annie's Place at Parkland is a collaboration between Parkland hospital and Annie's Place, a Dallas area nonprofit, to provide free drop in childcare for families who need to access medical care.
YesNo
My Parkland Provider/ClinicOther Provider/ClinicFriend/FamilyParkland Employee
Moody ClinicWISH ClinicNICUOther
Parkland Email*
example@phhs.org
Which department do you work for?*
What is your role?
* WEEKEND CARE IS A SEPARATE PROGRAM FOR ALL HOSPITAL EMPLOYEES AT PARKLAND AND CHILDREN'S HEALTH. IF YOU ARE INTERESTED IN OUR WEEKEND PROGRAM, PLEASE LET OUR REPRESENTATIVE KNOW DURING YOUR INTERVIEW CALL.

Applicant Information

Parent/Legal Guardian of the children needing care.
Parent/Legal Guardian #1*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Email*
example@example.com
Home Phone
Cell Phone *
Address *

Street Address

Street Address Line 2

CityState

Zip Code
Race: Parent/Legal Guardian #1*
Preferred Language: Parent/Legal Guardian #1 *
Driver's LicenseState ID/ Real IDMilitary IDCertificate of Naturalization/CitizenshipU.S. PassportEnhanced Tribal CardsOther
Form of Identification ID Number: Parent Legal Guardian #1*
The number on the chosen form of identification listed above
YesNo
Parent/Legal Guardian #2*

First NameLast Name
MaleFemaleNon-BinaryOther
Cell Phone *
Home Phone
Work Phone
Email Address
YesNo
Address: Parent/Legal Guardian #2 *

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Language: Parent/Legal Guardian #2*
Driver's LicenseState ID/ Real IDMilitary IDCertificate of Naturalization/CitizenshipU.S. PassportEnhanced Tribal CardsOther
Form of Identification ID Number: Parent Legal Guardian #2*
The number on the chosen form of identification listed above

2024 Enrollment Application