Early Learning Enrollment Application

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1. Parent/Guardian Name (Required.)

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2. Parent/Guardian Email (Required.)

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3. Parent/Guardian Telephone Number (Required.)

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4. Home Address (Required.)

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5. Child's Name (Required.)

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6. Child's Dat of Birth (Required.)

Date of Birth

Date

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7. Child's Age Group (Required.)

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 (Required.)

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) (Required.)

Monday

Tuesday

Wednesday

Thursday

Friday

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10. How will care be paid for ? (Required.)

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? (Required.)

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? (Required.)

Yes

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13. If yes, please specify the allergies (Required.)

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14. Does your child have any special needs? (Required.)

Yes

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15. If yes, please specify the special needs (Required.)

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16. Any additional information we should know about your child? (Required.)

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17. When would you like your child to start? (Required.)

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. (Required.)

Yes

Early Learning Enrollment Application

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* 1. Parent/Guardian Name (Required.)

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* 2. Parent/Guardian Email (Required.)

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* 3. Parent/Guardian Telephone Number (Required.)

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* 4. Home Address (Required.)

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* 5. Child's Name (Required.)

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* 6. Child's Dat of Birth (Required.)

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* 7. Child's Age Group (Required.)

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* 8. Preferred Enrollment Schedule (Required.)

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

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* 10. How will care be paid for ? (Required.)

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

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* 12. Does your child have any allergies? (Required.)

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* 13. If yes, please specify the allergies (Required.)

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* 14. Does your child have any special needs? (Required.)

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* 15. If yes, please specify the special needs (Required.)

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

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

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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. (Required.)

1. Parent/Guardian Name (Required.)

2. Parent/Guardian Email (Required.)

3. Parent/Guardian Telephone Number (Required.)

4. Home Address (Required.)

5. Child's Name (Required.)

6. Child's Dat of Birth (Required.)

7. Child's Age Group (Required.)

8. Preferred Enrollment Schedule (Required.)

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

10. How will care be paid for ? (Required.)

11. Which location are you looking to enroll your child? (Required.)

12. Does your child have any allergies? (Required.)

13. If yes, please specify the allergies (Required.)

14. Does your child have any special needs? (Required.)

15. If yes, please specify the special needs (Required.)

16. Any additional information we should know about your child? (Required.)

17. When would you like your child to start? (Required.)

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