Early Learning Enrollment Application

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* 1. Parent/Guardian Name

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* 2. Parent/Guardian Email

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* 3. Parent/Guardian Telephone Number

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* 4. Home Address

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* 5. Child's Name

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* 6. Child's Dat of Birth

Date of Birth

Date

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* 7. Child's Age Group

Infant (0-1 year)

Young Toddler (1-2 years)

Older Toddler (2-3 years)

Preschool (3-4 years)

Pre-Kindergarten (4-5 years)

School Age (Kindergarten through 7th Grade)

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* 8. Preferred Enrollment Schedule

Full-time (5+ hours per day)

Part-time (Less than 5 hours per day)

Before and/or After-school

Other

Summer Camp

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* 9. Days of the Week Needed (Select all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

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* 10. How will care be paid for ?

Private Pay

Subsidy (ELRC, CCAMPIS, DHS)

PHLpreK or PreK Counts (PKC)

Early Head Start (EHS)

Other

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* 11. Which location are you looking to enroll your child?

Location 1: 6355 Cardiff Street, Philadelphia, PA 19149 (Mayfair)

Location 2: 5828 Torresdale Avenue, Philadelphia, PA 19135 (Wissinoming)

Location 3: 5103 Torresdale Avenue, Philadelphia, PA 19124 (Frankford) (pending)

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* 12. Does your child have any allergies?

Yes

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* 13. If yes, please specify the allergies

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* 14. Does your child have any special needs?

Yes

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* 15. If yes, please specify the special needs

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* 16. Any additional information we should know about your child?

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* 17. When would you like your child to start?

Date

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* 18. Do you have any more children you would like to enroll? If yes, please complete a form for each child.

Yes