Enrollment Application
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Information About the Child
Child's Full Name *
Child's Date of Birth *
MM
/
DD
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YYYY
Living address (include city and zip) *
Child's primary language *
Child's Gender *
Required
Parent Guardian's full name *
Parent Guardian's date of birth *
MM
/
DD
/
YYYY
Email address
Phone Number
Current Employment Status *
Parent's last year of school completed
Language(s) spoken
Any Parent History of (mark all that apply)
Additional Parent Guardian's full name *
Additional Parent Guardian's date of birth *
MM
/
DD
/
YYYY
Additional Parent's Email address
Additional Parent's Phone Number
Current Employment Status *
Additional Parent's Last year of school completed
Additional Parent's Language(s) spoken
Additional Parent's History (mark all that apply)
Is child living under any of the following circumstances? (check all that apply)
Clear selection
Number of children and adults that are being supported with the same income? *
Does your child have an IEP or IFSP?
Clear selection
By submitting the form you hereby certify and acknowledge that the information provided (including source of income) is true and correct to the best of your knowledge. You understand that your child may be withdrawn from enrollment if any information you have provided proves to be false. By submitting, you are further verifying that you understand that submitting an application does not guarantee enrollment. Please type in your name. *
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