Brooklyn Little Learners Application

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Child’s Full Name

Date of Birth (MM/DD/YYYY):

Age at Start Date:

YYYY

Ideal Start Date:

YYYY

Program Applying For (check one):

Infant/Toddler

Two's Program

Three's Program

Summer Camp

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Preferred Location:

Park Slope Little Learners (463 6th Ave) *Two's and Three's Only

Windsor Terrace Little Learners (3001 Fort Hamilton) *Infants/Toddlers, Two's and Three's

35 Terrace Place *Infants/Toddlers

425 18th St *Infants/Toddlers

19 Windsor Place *Infants/Toddlers

501 8th St *Infants/Toddlers

Option 7

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Preferred Schedule (check one):

2 Days per Week

3 Days per Week

4 Days per Week

5 Days per Week

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Requested Days (if applicable):

Monday

Tuesday

Wednesday

Thursday

Friday

Parent / Guardian InformationParent / Guardian #1

Full Name:

Relationship to Child:

Phone Number:

Email Address:

Home Address:

Immunizations

I understand that my child must be immunized in accordance with New York City Department of Health regulations.

I will submit all required health and immunization records prior to enrollment.

Additional Information: Is there anything you would like us to know about your child (temperament, routines, comfort items, etc.)?

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