Early Childhood Program Enrollment Form

Early Care & Education Enrollment Form

Please complete all applicable fields on the form below. Press the 'submit enrollment form' button at the bottom of the form, and your enrollment form will be placed under review. If you would rather complete the paper form, you can retrieve it here. You will need adobe acrobat reader in order to view and print it.

Once you submit your enrollment form, you will be sent to a confirmation page. If you wish to return to the previous page without completing the form, click on the grey 'x' in the upper or lower right of this enrollment form.

Anything marked with a red asterisk * is required:

Name of Program: *
Contact Name: *	Title:
Address: *
Address (Suppl):
City: *	State: *	Zip: *
Phone: *	Fax:
Email Address :	County: *

How would your early childhood program be classified? (please check only one):

	Licensed Child Care Center	Starting Points Center
	Regulated Family Facility (7 - 12 children)	Certified Home Care (1 - 6 children)
	Head Start/Early Head Start Program	No Preference

How many children is your program approved to serve?

Please indicate the age groups and types of care currently offered at your center:

	Infant	Middle School Age
	Toddler	Children With Special Needs
	Preschool	Other
	Elementary School Age

Complete the following section ONLY if there is a health professional with whom you would like to be linked.

Name of Health Care Professional:*
Name of Practice:*
Address: *
Address (Suppl):
City: *	State: *	Zip: *
Phone: *	County:*

Once you are sure all of the above information is correct, press the 'submit enrollment form' button below.