COLLAB-LAB ENROLLMENT FORM

Collaborative for Children’s (CC) mobile education program offers one of our most innovative programs to-date. The Collab-Lab is a mobile learning lab that brings critical, future-focused early childhood education directly to the community. Our summer services engage a child between the age of 3-5 alongside an adult from their family in hands on learning through Science, Technology, Engineering, Art, Math (S.T.E.A.M), and Literacy. Summer programming will occur once a week for 45 minutes, for a 4-week period. This dual-generation program corresponds to the five general attributes of our Collab Kid: a global learner, an innovative creator, a leader, a digital learner and a problem-solver

If you are interested in enrolling in this program, please take a moment to complete the information below.

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* Parent or Guardian Information

First Name *

Last Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

Child Information

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* Child 1 Information

First Name

Last Name

Date of Birth

Age

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* Child 2 Information

First Name

Last Name

Date of Birth

Age

General Information

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* How did you hear about this program?

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* Primary language spoken in your household:

English

Spanish

Other (please specify)

Please check all that apply

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* I am interested in participating in CC's mobile education program because:

My child is currently age 3 to 5

I am willing and available to join and support my child on the Collab-Lab on the designated day for my site.

I am willing and available to participate and support my child through home learning extension activities provided by CC staff throughout the week

I am willing and available to participate in collaborative virtual sessions facilitated by a CC staff, to discuss family empowerment education and support

I am willing and available to complete a pre and post survey related to track overall progress

Agreement and Terms:

I verify that the information provided is true and correct. I understand the information given on this application will be used for eligibility determination. I understand that an incomplete application is not considered in the review process. I understand that completing this form does not guarantee selection and participation in Collaborative for Children’s mobile education program.

COLLAB-LAB ENROLLMENT FORM

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* Parent or Guardian Information

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* Child 1 Information

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* Child 2 Information

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* How did you hear about this program?

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* Primary language spoken in your household:

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* I am interested in participating in CC's mobile education program because:

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* Printed Name

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* Initials

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* Date