Pre K International Child Care Center Enrollment
Parents can enroll a child in a course, share household, childcare, schedule, medical, emergency contact, and consent information. Data should export cleanly to Google Sheets.
Parent/Guardian Information
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
Call
Text
Email
Household Information
Total Number of People in Household
*
Household Members (Names and Ages)
*
Additional Adults Contribute Income in the Home
*
Yes
No
Child Information
Child Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Currently Enrolled in Child Care
Yes
No
Current Child Care Provider
Parent Work/School Status
Employment Status
*
Employed Full-Time
Employed Part-Time
Self-Employed
Unemployed
In School / Training Program
Employer / School Name
Weekly Work / School Hours
Financial/Assistance Information
Estimated Monthly Household Income Range
*
$0–$1,500
$1,501–$3,000
$3,001–$5,000
$5,000+
Currently Receiving Assistance Programs
*
DHHS Child Care Subsidy
SNAP (Food Assistance)
Medicaid
TANF (Cash Assistance)
None
Applied for Childcare Assistance Before?
*
Yes
No
Childcare Assistance Application Result
Approved
Denied
Pending
Not Sure
Additional Eligibility Factors
Foster Child
Adopted Child
Child with Special Needs / IEP
Seeking employment
Enrolled in school/training
Other
Program / Schedule Preferences
Course/Classroom Selection
*
Please Select
Option 1
Option 2
Option 3
Preferred Schedule
*
Full-Time (30+ hrs/week)
Part-Time
Drop-In
Preferred Start Date
*
-
Month
-
Day
Year
Date
Preferred Hours
Transportation Needed
Yes
No
Emergency Contacts
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Child
*
Consent / Authorization
Parent acknowledgment of policies
*
Authorization signature
*
Authorization date
*
-
Month
-
Day
Year
Date
Submit Enrollment
Submit Enrollment
Should be Empty: