Wilshire ECLC Waitlist Form

Submission

MonthDayYear

Kid A.T Heart
Youth Development Center
55 South Gammon Rd. Madison, WI 53717
Email: contact@mykidatheart.com Website: mykidatheart.com

Kid A.T Heart Youth Development Center
Waitlist Form 2024-25

Child's Name*

First NameLast Name

Birth Date*

MonthDayYear

Gender*

**Child must be 4 years old on or before

August 31st 2024 and starting 4-k September 2024**

Parents' Name(s):*

Phone Number*

Area CodePhone Number

Email*

Age Group (on or before August 31st 2024)*

Part-time care- 3 nights per week or 2 nights and 1 weekend day per week

Full-Time care- 4 nights and 1 weekend day per week or 5 nights per week

Weekend care- Saturdays only or 1 week night (Friday or Sunday) and Saturday only

Type of Care Needed

Part-TimeFull-TimeWeekend

Additional Comments i.e. schedule needed/expected start date