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Early Ed Interest Form
Early Education Interest Form
Today's Date
*
Date Format: MM slash DD slash YYYY
Leave no sections blank please. Applications with blank sections cannot be processed.
Time
:
HH
MM
AM
PM
Child's Name
*
First
Last
Child's Date of Birth
*
Date Format: MM slash DD slash YYYY
Parent's Name
*
First
Last
Parent's Email
*
Mailing Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Cell Phone
*
**Inability to reach you via the contact information you have provided here will result in 1st time refusal or deactivation, which ever status is appropriate at that time.
Business Phone
Alternate Contact
*
I am the:
*
Parent
Grandparent
Legal Guardian
Payment Method
*
Private Pay
ELC Funding
Scholarship
Are you on the Early Learning Coalition waitlist?
*
Yes
No
If Yes, what is your ELC Confirmation #
If Yes, how long have you been on the waitlist!
Untitled
First Choice
Second Choice
Third Choice
Are you working 25 hours or more a week
*
Yes
No
Are you attending school?
*
Yes
No
My child has a sibling already attending Jack & Jill
*
Yes
No
If Yes, what is the child's name?
First
Last
I have an older child who attended Jack & Jill
*
Yes
No
If Yes, what is the child's name?
First
Last
I have another child on the waitlist
*
Yes
No
If Yes, what is the child's name?
First
Last
Priority of acceptance: 1. Siblings of children already attending the Center 2. Children receiving subsidized funding
If you have a school-age child, would you like to enroll your child in The Madeline Halmos Academy? (grades K - 4)
*
Yes
No
If Yes, what is the child's name?
First
Last
If Yes, what is the child's date of birth?
Date Format: MM slash DD slash YYYY
How did you hear about us?
*
Pamphlet
On-line ad
Email
Broward College CCAMPIS referral
Other referral (if this is checked, enter name below)
Who referred you?
I hereby attest that I am employed or enrolled in school with at least 12 credits per week and must remain so in order to receive services.
*
I agree to the statement above
Please enter your full name to sign
*
