25/26 ACP FIVES Application

2025-2026

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

First NameLast Name
Date of Birth*

MonthDayYear
Date
Date*

MonthDayYear
Date
Status of Applicant and Due Date

Currently Enrolled -- October 18, 2024Sibling of Currently Enrolled -- October 19, 2024Children's Community Development Center Families -- October 22, 2024Community applicant -- October 24, 2024
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
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
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*

FIVE PART DAYS (8:30 - 2:30) $17,250 per year **FIVE FULL DAYS (7:30 - 6:00) $23,000 per year **EXTENDED PLAY FOR PART DAY CHILDREN (2:30 - 4:30) $700.00 per day/per year**
** Based on 24/25 Tuition Rates
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 to A Child's Place, or online at https://securepayment.link/achildsplace/
Signature

Clear
Should be Empty:

Primary Contact/Guardian Information

Secondary Contact/Guardian Information

** Based on 24/25 Tuition Rates