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ELC Enrollment Form
Please verify reCaptcha before submitting the form.
*
Please enter the number of child/ren
Please Select One
1
2
3
Child 1 Enrollment Form
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Child's Name
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Child's Date of Birth
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Primary Language
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Identifying Marks
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Eye Color
*
Hair Color
*
Skin Color
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Gender
Please Select One
Male
Female
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Height
*
Weight
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Allergies/Special Diet
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Does your child have an Individual Health Plan for a chronic health condition?
Please Select One
Yes, I will send you a copy as soon as possible.
No.
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I will provide a current health Certificate of Immunization & evidence of current physical exam signed by child's pediatrician.
I will contact my child's pediatrician for a current health form and send you a copy ASAP. Physical Exams are valid for one year.
Child 2 Enrollment Form
Child's Name
Child's Date of Birth
Primary Language
Identifying Marks
Eye Color
Hair Color
Skin Color
Gender
Please Select One
Male
Female
Height
Weight
Allergies/Special Diet
Does your child have an Individual Health Plan for a chronic health condition?
Yes, I will send you a copy as soon as possible.
No.
I will provide a current health Certificate of Immunization & evidence of current physical exam signed by child's pediatrician.
I will contact my child's pediatrician for a current health form and send you a copy ASAP. Physical exams are valid for one year.
Child 3 Enrollment Form
Child's Name
Child's Date of Birth
Primary Language
Identifying Marks
Eye Color
Hair Color
Skin Color
Gender
Please Select One
Male
Female
Height
Weight
Allergies/Special Diet
Does your child have an Individual Health Plan for a chronic health condition?
Yes, I will send you a copy as soon as possible.
No.
I will provide a current health Certificate of Immunization & evidence of current physical exam signed by child's pediatrician.
I will contact my child's pediatrician for a current health form and send you a copy ASAP. Physical exams are valid for one year.
Additional Health Information
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Child(ren)'s Physician (First & Last Name)
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Street Address
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City, State, Zip
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Phone Number
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Are there any custody agreements, court orders and restraining orders pertaining to your child that we should know about?
Please Select One
Yes, I will send you a copy as soon as possible.
No.
Parent 1 Information
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Parent/Guardian Name (First & Last)
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Relationship to Child
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Street Address
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City, State, Zip
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Home Phone
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Cell Phone
*
Email Address
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Business Name
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Business Address
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Business City, State, Zip
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Business Phone Number
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Hours at Work
Parent 2 Information
Parent/Guardian Name (First & Last)
Relationship to Child
Cell Phone
Email Address
Business Name
Business Address
Business City, State, Zip
Business Phone Number
Hours at Work
Parent Signature & Date
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With whom does your child(ren) reside?
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By typing my name below and clicking "Submit" I hereby constitute that this is my electronic signature for legal purposes.
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Date
Sun, July 6 2025 10 Tammuz 5785
