Enrollment Application

ENROLLMENT APPLICATION

1. INDICATE YOUR PREFERENCE:
Available at Ambler, Broomall, Melrose Park and Wallingford locations

2. PREFERRED LOCATION:

3. WHEN WOULD YOU LIKE TO ENROLL YOUR CHILD?

4. 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

How did you hear about us?

Prior Enrollment

Application Completed by

5. MOTHER'S INFORMATION:

First Name:		Last Name:
Home Address:		Home Telephone #:
City, State and Zip
Home E-mail Address:
Cell Phone #:		Beeper (Pager)#:
Occupation:		Employer:
Business Address:
Business Telephone #:
Business E-mail Address:

6. FATHER'S INFORMATION:

First Name:		Last Name:
Home Address:		Home Telephone #:
Home E-mail Address:
Cell Phone #:		Beeper (Pager)#:
Occupation:		Employer:
Business Address:
Business Telephone #:
Business E-mail Address:

6. NAME OF ENROLLING PARENT:

7. 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Age When Withdrawn: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#:

8. 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.

Thank you for your interest in Federation Early Learning Services

Click here for a checklist about how to choose quality childcare.