25/26 ACP FIVES Application

2025-2026

A Child's Place Fives Application

APPLICATIONS DO NOT ROLL OVER - YOU MUST REAPPLY EACH NEW SCHOOL YEAR
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Date

MonthDayYear
Date
Status of Applicant and Due Date
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
Primary Contact/Guardian Phone
Format: (000) 000-0000.
Primary Contact/Guardian Phone Type
Primary Contact/Guardian Email
example@example.com
Primary Contact/Guardian Relationship to Child
Secondary Contact/Guardian Information

If First Contact cannot be reached
Secondary Contact/Guardian Name

First NameLast Name
Secondary Contact/Guardian Phone
Format: (000) 000-0000.
Secondary Contact/Guardian Phone Type
Secondary Contact/Guardian Email
example@example.com
Secondary Contact/Guardian Relationship to Child
Fives Program - 5 years by 12/31/25
** Based on 24/25 Tuition Rates
Desired Extended Play Day(s):
Date

MonthDayYear
Date
Signature
Should be Empty:

Primary Contact/Guardian Information