Early Learning Center Screening Request
ELC Screening Request Form
Child's Legal Name (last, first, middle) *
Child's Date of Birth *
MM
/
DD
/
YYYY
Birth City, State, Country *
Gender (check one) *
Ethnicity (check one) *
Race (check one or more) *
Required
Home language if other than English
Primary/1st Parent/Legal Guardian Name (last, first) *
Relationship to the child: *
Home address (street address, city, state, zip code *
Preferred phone number: *
Secondary/2nd Parent/Legal Guardian Name (last, first) If this is a foster child, DCFS info needs to be added below.
Relationship to the child:
Clear selection
Address (if different from above) street address, city, state, zip code)
Preferred phone number for 2nd parent/guardian
Alternate Phone Number
Has child attended a previous preschool? *
If yes, what is the name of the school?
Please list any siblings in the home and their ages.
Do you have any concerns for your child? *
What is your email address? *
Submit
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