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Request Enrollment Packet / Solicitar Paquete de Inscripción
Request our enrollment packet and family handbook for your child. You will receive both by email within a few minutes after you submit.
Solicite nuestro paquete de inscripción y manual para familias. Recibirá ambos por correo electrónico unos minutos después de enviar.
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* Indicates required question
Parent / Guardian Full Name / Nombre Completo del Padre / Madre / Tutor
*
Your answer
Your Email Address / Su Correo Electrónico
*
We will email the packet to this address. / Le enviaremos el paquete a esta dirección.
Your answer
Phone Number / Número de Teléfono
Your answer
Child Name(s) / Nombre(s) del Niño/a
*
If submitting for more than one child, list all names separated by commas. / Si es para más de un niño/a, separe los nombres con comas.
Your answer
Child Date of Birth / Fecha de Nacimiento del Niño/a
*
MM
/
DD
/
YYYY
Which center are you interested in? / ¿En cuál centro está interesado?
*
726 Washington Street
336 S 18th Street
Not sure yet / Aún no estoy seguro/a
Are you using Childcare Works (CCW) subsidy? / ¿Usa el subsidio Childcare Works (CCW)?
*
Reminder: if using CCW you must also contact ELRC Region 13 at (484) 651-8000 or
ELRC13@cscinc.org
.
Yes — I have already contacted ELRC / Sí, ya me comuniqué con ELRC
Yes — I have NOT yet contacted ELRC / Sí, pero AÚN no me he comunicado con ELRC
No — private pay / No, pago privado
Not sure yet / Aún no estoy seguro/a
When are you hoping to start? / ¿Cuándo espera comenzar?
Approximate is fine — pick any nearby date. / Aproximado está bien — elija cualquier fecha cercana.
MM
/
DD
/
YYYY
Anything else we should know? / ¿Algo más que debamos saber?
Your answer
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