Federation Early Learning Services

2. INDICATE YOUR PREFERENCE:
*Available at Ambler, Center City, Broomall, Melrose Park, Elkins Park and Wallingford locations

3. PREFERRED LOCATION*:

4. WHEN WOULD YOU LIKE TO ENROLL YOUR CHILD?*

5. NAME (S) OF ENROLLING CHILDREN:

CHILD 1	FIRST	LAST	BIRTHDATE	GENDER
CHILD 2	FIRST	LAST	BIRTHDATE	GENDER
CHILD 3	FIRST	LAST	BIRTHDATE	GENDER

OTHER CHILDREN IN HOME:

OTHER CHILD1	FIRST	LAST	BIRTHDATE	GENDER
OTHER CHILD2	FIRST	LAST	BIRTHDATE	GENDER
OTHER CHILD3	FIRST	LAST	BIRTHDATE	GENDER

Prior Application Date

Prior Enrollment

6. PARENT #1 INFORMATION:

First Name*:		Last Name*:
Home Address:		Home Telephone*:
City, State and Zip*:
Home E-mail Address:
Cell Phone:
Occupation:		Employer:
Business Address:
Business Telephone:
Business E-mail Address:

PARENT #2 INFORMATION:

First Name:		Last Name:
Home Address:		Home Telephone:
Home E-mail Address:
Cell Phone:
Occupation:		Employer:
Business Address:
Business Telephone:
Business E-mail Address:

7. NAME OF ENROLLING PARENT:

8. PRIOR CHILD CARE EXPERIENCE

If your child was previously enrolled in a child care/preschool program, please complete this section:
a. Name of Program:
Age When Enrolled:
Age When Withdrawn:
Reason For Leaving:
Describe your child's experience:
b. Permission to contact previous program?
Contact Person:
Address:
Telephone#:

9. FAMILY SITUATION

a. Marital Status
b. Please help us better meet your child's needs by sharing information about your family situation that may impact him/her.

enroll

Enrollment Application