Early Childhood Center

To submit an application via e-mail, please first read the Spring 2013 Enrollment Information Letter (PDF). Next, complete the below form and click submit. The Center’s Director will contact you within 5-7 days to discuss your application. We recommend that you submit an Application at least 1 month prior to your desired start date. Children typically begin enrollment at the start of our Fall (August-December), Spring (January-May), or Summer (May-August) semesters. Children may; however, begin enrollment at other times to meet your child care needs.

Application for Enrollment

 * required
Date of Application *
Semester Applying For *     Year:

 

Child Information

Last Name *
First Name/Child Goes By *
Middle Initial *
Gender *
Date of Birth *
Current Age *

 

Family Contact Information

Street Address *
City *
Zip Code *
Phone *
Email *

 

Requested Schedule

Schedule in :15 minute increments – :00, :15, :30, :45)
We are open from 7:15 am - 5:15 pm.
Minimum enrollment is 2 days; minimum day is three consecutive hours.

 *
Monday
Tuesday
Wednesday
Thursday
Friday
Arrive
Depart

 

Parent/Guardian Information

Anyone listed as a parent/guardian automatically has the right to pick-up enrolled child. Please fill out either Mother/Guardian or Father/Guardian.

  Mother/Guardian Father/Guardian
Name *
Home Phone *
Cell Phone *
Work Phone *
Employer *
Relationship to Kish * Student
Community
Employee
Child lives with *

 

Authorized to Pick-Up Child / Emergency Contact Information

In addition to parents/guardians listed above, individuals listed below are authorized to pick my child up from the Center and may also be contacted in the event of an emergency.

  Name Phone Address Relationship to family
1
2
3

 

Emergency Medical Information

Physician Name Phone Address Allergies List Allergies

 

Tuition Payment Information

Tuition Payment Information *
I will be "self pay" and pay ECC tuition myself.
I have applied or will apply for financial assistance through 4-C.
I am interested in learning more about 4-C financial assistance. Please contact me.

 

Comments:

I have read the Spring 2013 Enrollment Information Letter.

Please make sure you have filled out the form completely before clicking submit. After clicking submit, you will see a confirmation page and receive a confirmation message from the Center’s Director. If you do not receive this message, you may have left off required responses and your application was not submitted successfully. Please complete and submit the form again or phone the Center at 815-825-2086, ext. 2150 for assistance.

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