School Age Application for Admission

Application for Admission (School Age Children)

Zearing Child Enrichment Center - 633 Masonic Drive, Princeton, Illinois
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Current Age
Male/Female
School attending in Fall:
Name of School
Grade entering:
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
First Day of Attendance
Days we would like to attend
Before School?
After School?
*Full-time child care needs take precedence over part-time child care needs.
I will bring my child to the center at:
I will pick my child up at:
Does your child have an "active" Individualized Education Plan (IEP)?
If yes, a copy must be provided prior to enrollment.
Does your child receive special services? (ex. Speech, Occupational, Physical, Developmental or Behavioral therapies). If yes, where?
Does your child receive any counseling? If yes, where?
We would like to apply for a subsidized slot (Per state: for families who qualify by income and family size)
Parent/Guardian's Name

First NameLast Name
Relationship to child:
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Employer
Parent/Guardian's Name

First NameLast Name
Relationship to child:
Email Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Employer
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Other Children in Family
Additional Notes or Comments
How did you hear about us?
Please complete this form and return it to the center. If there is no immediate opening, your child's name will be placed on the “waiting List”. We will notify you as soon as an opening occurs. At enrollment time, there will be a $60.00 non-refundable application fee and an annual $45.00 activity fee due. (Activity Fee non-refundable after 30/days from enrollment date).

No family will be discriminated against because of race, sex, religion or national origin. All information listed above is confidential.
E-Signature (Type Name)
Should be Empty:

Application for Admission (School Age Children)