Annual Family Membership for Eligible PreK Families

Annual Family Membership for Eligible PreK Families

Please complete the form below to apply for a free Family Membership to Eureka!.
Name of Eligible Student Must be 0-5 yrs old*

First NameLast Name
Name of Parent or Guardian*

First NameLast Name
Birthdate of PreK Student*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Email*
Aplication Approval & Membership Process Sent Via Email
Phone Number*

Area CodePhone Number
Please provide a brief statement of why you are applying for an annual family membership:*
Proof of Eligibility*

Upload a File
Medicaid Card or Marillac Clinic Card or if one of these cards are not available, please submit a statement of need. Cancelof
What PreK school (if any) does your child attend?
School Name
If there was a free program to attend with your child, to learn about math, science and childhood development would you be interested?

Yes, I would be interested in a free PreK programNo, I would not be interested in a free PreK Program
Where and when would you be likely to attend a free PreK program? (Check all that apply)

WeekdaysWeekendsMorningsAfternoonsAt Eureka!At a Library Branch
By signing this application, I certify that all information provided on this application is true and correct. I understand that Eureka! staff may verify my application materials and that deliberate misrepresentation on my application may subject me to disqualification from the Eureka! Youth Scholarship Program.*

Clear
Parent/Guardian Signature
Should be Empty: