East Peoria District 86 Early Childhood Education Program Eligibility Application Form 20-21
This information will be kept confidential, & will ONLY be used to determine placement in program.
* Required
Email address
*
Your email
Child's Name:
*
Your answer
Child's Birth Date:
*
MM
/
DD
/
YYYY
Address:
*
Your answer
Home/Permanent Telephone:
*
Your answer
Work Place:
*
Your answer
Work Telephone:
*
Your answer
Parent/Guardian Name:
*
Your answer
Relationship to Child:
*
Your answer
Additional Parent/Guardian Name:
*
Your answer
Additional Relationship to Child:
*
Your answer
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