ReVillage Enrollment Form
Please read the ReVillage Handbook before completing this enrollment form. You can read the handbook here:
Once we have received your completed enrollment form, our coordinator will be in contact within 3-5 business days.

Haga clic en el siguiente enlace para nuestro formulario de inscripción en español:
Your First & Last Name
The following questions will help us get to know you and your family. If you'd rather have a phone conversation with a staff person, please just indicate that in the answer boxes.
Clear selection
Phone Number
Email Address
Street Address
Child's Full Name
Child's Nickname (or name Child responds to)
Child's Pronouns
Enrollment Needed
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Days Needed
Child Lives With
Emergency Contact Name and Relationship to Child
Emergency Contact Phone Number
Who is authorized to pick you child up from the center?
Are you planning to utilize assistance through Baby Promise?
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