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*

MondayTuesdayWednesdayThursdayFriday
Before School?*

YesNo
After School?*

YesNo
*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)?*

YesNo
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)*

YesNo, we do not qualify
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?*

FriendFamily MemberRadioNewspaperSocial MediaOther
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 $50.00 non-refundable application fee and an annual $30.00 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)