Application for Enrollment

130 West Main Street

19 South Canal Street & 145 Northwest Drive

Plainville, CT 06062 860-747-3321

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Student Information

Full Name: ______

(Last) (First) (Middle) (Nickname)

Date of Birth: ______Sex: ______

Date of Enrollment: ______

Address: ______Apt. #______

Town: ______State: ______Zip:______Phone: ______

Hours to be Enrolled: ___:___a.m. to ___:___ p.m.

Child’s Ethnicity: _____African American _____Asian _____Caucasian _____Latino

_____Native American _____Pacific Islander _____Other______

Cultural Background: ______Religion: ______

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Family Information

Child lives with: ______

Adult #1:______Adult #2:______

Relationship to Child: ______Relationship to Child:______

Address: ______Address: ______

Home Phone: ______Home Phone: ______

Employer: ______Employer: ______

Employer’s Address: ______Employer Address: ______

______

Work Phone: ______Work Phone: ______

Cell Phone: ______Cell Phone: ______

Email Address: ______Email Address: ______

Parents are:

 Married  Living Together  Divorced  Separated  Widowed  Single

Other Household Members:

Name: ______Age: ______Relationship ______
Name: ______Age: ______Relationship ______
Name: ______Age: ______Relationship ______

Name: ______Age: ______Relationship: ______

Parent Authorization

____Yes ____No I give permission for my child to participate in field trips and other

activities during operating hours both transported and walking.

____Yes ____No I give consent for my child pictures to be taken and used for promotional

purposes including Facebook and/or the PELC website.

____Yes ____No I give permission to apply topical medications for first aid.

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(Parent Signature) (Date)

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Additional Information

How did you hear about us? ______Referred by: ______

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Why are services needed? ______Why do you wish to change? ______

Who cares for the child now? ______

Would you be willing to share your talents, hobbies, culture (traditions, foods, costumes, etc.) with the program?  YES  NO

If so what would you be willing to share? ______

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Thank you for choosing Plainville Early Learning Center!