Early Learning Enrollment Application

Question Title

* 1. Parent/Guardian Name

Question Title

* 2. Parent/Guardian Email

Question Title

* 3. Parent/Guardian Telephone Number

Question Title

* 4. Home Address

Question Title

* 5. Child's Name

Question Title

* 6. Child's Dat of Birth

Date of Birth

Date

Question Title

* 7. Child's Age Group

Infant (0-1 year)

Young Toddler (1-2 years)

Older Toddler (2-3 years)

Preschool (3-4 years)

Pre-Kindergarten (4-5 years)

School Age (Kindergarten through 7th Grade)

Question Title

* 8. Preferred Enrollment Schedule

Full-time (5+ hours per day)

Part-time (Less than 5 hours per day)

Before and/or After-school

Other

Question Title

* 9. Days of the Week Needed (Select all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Question Title

* 10. How will care be paid for ?

Private Pay

Subsidy (ELRC, CCAMPIS, DHS)

PHLpreK or PreK Counts (PKC)

Early Head Start (EHS)

Other

Question Title

* 11. Which location are you looking to enroll your child?

Location 1: 6355 Cardiff Street, Philadelphia, PA 19149 (Mayfair)

Location 2: 5828 Torresdale Avenue, Philadelphia, PA 19135 (Wissinoming)

Location 3: 5103 Torresdale Avenue, Philadelphia, PA 19124 (Frankford) (pending)

Question Title

* 12. Does your child have any allergies?

Yes

Question Title

* 13. If yes, please specify the allergies

Question Title

* 14. Does your child have any special needs?

Yes

Question Title

* 15. If yes, please specify the special needs

Question Title

* 16. Any additional information we should know about your child?

Question Title

* 17. When would you like your child to start?

Date

Question Title

* 18. Do you have any more children you would like to enroll? If yes, please complete a form for each child.

Yes