Jenkins ECLC Registration - New Families
PLEASE FILL OUT THIS FORM SEPARATELY FOR EACH OF YOUR CHILDREN. Thanks!
Registration fees will not be charged until we confirm your spot.
Questions? Contact Gina Benson at
or call 734-424-4180 ext. 1413.
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Your Phone Number
Second Parent or Guardian Name (type N/A if none)
Second Parent/Guardian Email
Second Parent/Guardian Phone
Student Full Name
Has this student previously attended care?
Yes - center-based care
Yes - home-based care
No - home with parent/guardian/relative
Is this child fully potty trained?
In progress with few accidents
Just starting training
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