Enrollment Application

Please include the following documents:

□ Immunization Records/Exempt Letter □ Current Well-Child Exam □ Current Dental Exam

□Medical Insurance # □ SNAP Number □Parent/Guardian ID □ IEP, if Needed□ Allergy Plan, if Needed

Child’s First Name: ______Last Name: ______

Child lives with: □ One parent/guardian □ Two parent/guardians
Parent(s)/Guardian(s) Relationship to the applicant: □ Foster Parent(s) □ Grandparents □ Aunt/Uncle
□ Biological/Adoptive Parent(s) □ Step Parent(s) □ Other
Parent/Guardian: □ Mother □ Father □ Other / Parent/Guardian: □ Mother □ Father □ Other
Name: / Name:
Address:
______
______/ Address:
______
______
Primary Phone: ______
□ Home □ Cell □ Work □ Message
Secondary Phone: ______
□ Home □ Cell □ Work □ Message / Primary Phone: ______
□ Home □ Cell □ Work □ Message
Secondary Phone: ______
□ Home □ Cell □ Work □ Message
Email Address:
______/ Email Address:
______
Student ID # / Student ID #
SSN # / SSN #
Are you currently in school? □ No □ Yes
Degree or program: ______
Hours per week in class and studying: ______/ Are you currently in school? □ No □ Yes
Degree or program: ______
Hours per week in class and studying: ______
Are you currently working? □ No □ Yes
Hours per week: ______/ Are you currently working? □ No □ Yes
Hours per week: ______
Financial Aid Status: □ Applied □ Receiving □Not Applicable
□ GI Bill □ Tribal Assistance □ Other: ______/ Financial Aid Status: □ Applied □ Receiving □Not Applicable
□ GI Bill □ Tribal Assistance □ Other: ______
Is your family currently homeless? (Temporarily living in shelters, hotels, vehicles or moving between homes of relatives and/or friends due to financial hardship) □ No □ Yes
Monthly Childcare cost will be paid by: □ Private Pay □ DSHS Childcare Subsidy □ Tribal Assistance

Child’s First Name: ______Last Name:______

Health and Development Information

Date of your child’s last Well Child Exam: ______

Has your child been diagnosed by a Health Care Provider with any of the following health conditions? (check all that apply)

□ Respiratory (Asthma, RSV, RAD, other): □ Diabetes □ Seizures □ Heart Condition □ Food Allergies:______

□ Other Allergies: ______□ Swallowing, feeding and/or special diet: ______

□ Hearing concerns: □ Vision concerns □ Tooth Pain/Decay/Bleeding Gums

□ Mental Health concerns: □ Drug/Alcohol affected □ Injury: ______

Has your child experienced any of the following? (Check all that apply)

□ Abuse/Neglect □ Former Foster Care □ Asked to leave a childcare center because of behavior

Does your child have a special need? (Check all that apply)

□ Individualized Education Plan (IEP) □ Individualized Family Service Plan (IFSP) □ A diagnosed disability

□ Early Intervention Birth to 3 program □ Special Needs Preschool – If yes, will your child be taking the bus? ______

Do you have concerns about your child’s development? □ No □ Yes

If yes, check all that apply: □ Speech/Talking □ Fine Motor (grasping, drawing, writing, and/or dressing)

□ Behavior (hitting, biting, having tantrums and/or not cooperating)

□ Gross Motor (walking, climbing, throwing, spinning, lack of eye contact, loss of skills)

□ Other concerns: ______

Parent/Guardian Signature: ______Date: ______

***Return this form and required documents to the TCC Early Learning Center***

Please initial and date each of the following:

Notified: ______Tour: ______Meet Teacher: ______Orientation Date: ______

First Date of Attendance: ______Last Date of Attendance: ______

As of May, 2016