Early Learning Centers Enrollment Form
Enrollment Information
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Child's legal name *
Child's date of birth (month/date/year): *
Childs sex *
Is your child potty trained? *
Child's Ethnicity? *
Child's Race? *
 First Parents Name: *
Second Parents Name: *
Other Parents Name:
How many people live in the home? *
What is the average monthly income of everyone working in this household?  (please bring the most 2 recent check stubs for everyone working in the household.) *
Which center are you interested in enrolling at? *
On what date would you like your child to start? *
Do you want to enroll this child: *
What days will your child attend (check all that apply): *
What hours will your child attend: *
What is the child's home address, including zip code? *
What is the name of the parent the child lives with? *
What is this parents email address *
What is this parents cell phone number? *
Where does the parent work? *
What is the parents work phone number? *
Can this parent: *
Other parents name?
Other parents address, including zip code?
Other parents cell phone number
Other parents place of work?
Other parents place of work telephone number?
Can this parent *
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