Date of Last Upload:
Tuesday, June 11, 2024
Student Enrollment Form
New Student Information
Select the Submit Application tab after you have filled in all information including students, primary and secondary family, and emergency/contacts. Use the tab buttons to select the pages to fill in the information.
*
Required fields are bold.
Student's Information
Primary Family Information
Secondary Family Information
Contact Information
Submit Application
Student 1
*
Last Name
*
First Name
Middle Name
*
Preferred Name (Name you would like us to use in the classroom)
*
Date of Birth (mm/dd/yyyy)
*
Gender
<None>
Female
Male
Child has an IEP or IFSP
Suffix
<None>
Jr.
III
IV
Name of Resource Teacher
*
Grade Level
<None>
T/Th Parents' Morning Out (2 years by Sept. 30)
W/F Parents' Morning Out (2 years by Sept. 30)
MWF Parents' Morning Out (2 1/2 years by Sept. 30)
T/Th Preschool (3 years by Sept. 30)
MWF Preschool (3 years by Sept. 30)
MWF PreKindergarten (4 years by Sept. 30)
M-F PreKindergarten (4 years by Sept. 30)
M-F JrK (Older 4's and Young 5's, 5 by 1/31/25)
*
Allergies
<None>
Eggs
Fish/Shellfish
Medication
Milk
None
Other
Peanut
Sesame
Soy
Tree Nuts
Wheat
Best # during school hour Phone
Asthma
Emergency meds kept at school
Best E-Mail
*
Food Restrictions
*
Siblings Names and Ages
Additional Comments
Student 2
*
Last Name
*
First Name
Middle Name
*
Preferred Name (Name you would like us to use in the classroom)
*
Date of Birth (mm/dd/yyyy)
*
Gender
<None>
Female
Male
Child has an IEP or IFSP
Suffix
<None>
Jr.
III
IV
Name of Resource Teacher
*
Grade Level
<None>
T/Th Parents' Morning Out (2 years by Sept. 30)
W/F Parents' Morning Out (2 years by Sept. 30)
MWF Parents' Morning Out (2 1/2 years by Sept. 30)
T/Th Preschool (3 years by Sept. 30)
MWF Preschool (3 years by Sept. 30)
MWF PreKindergarten (4 years by Sept. 30)
M-F PreKindergarten (4 years by Sept. 30)
M-F JrK (Older 4's and Young 5's, 5 by 1/31/25)
*
Allergies
<None>
Eggs
Fish/Shellfish
Medication
Milk
None
Other
Peanut
Sesame
Soy
Tree Nuts
Wheat
Best # during school hour Phone
Asthma
Emergency meds kept at school
Best E-Mail
*
Food Restrictions
*
Siblings Names and Ages
Additional Comments
Student 3
*
Last Name
*
First Name
Middle Name
*
Preferred Name (Name you would like us to use in the classroom)
*
Date of Birth (mm/dd/yyyy)
*
Gender
<None>
Female
Male
Child has an IEP or IFSP
Suffix
<None>
Jr.
III
IV
Name of Resource Teacher
*
Grade Level
<None>
T/Th Parents' Morning Out (2 years by Sept. 30)
W/F Parents' Morning Out (2 years by Sept. 30)
MWF Parents' Morning Out (2 1/2 years by Sept. 30)
T/Th Preschool (3 years by Sept. 30)
MWF Preschool (3 years by Sept. 30)
MWF PreKindergarten (4 years by Sept. 30)
M-F PreKindergarten (4 years by Sept. 30)
M-F JrK (Older 4's and Young 5's, 5 by 1/31/25)
*
Allergies
<None>
Eggs
Fish/Shellfish
Medication
Milk
None
Other
Peanut
Sesame
Soy
Tree Nuts
Wheat
Best # during school hour Phone
Asthma
Emergency meds kept at school
Best E-Mail
*
Food Restrictions
*
Siblings Names and Ages
Additional Comments
Student 4
*
Last Name
*
First Name
Middle Name
*
Preferred Name (Name you would like us to use in the classroom)
*
Date of Birth (mm/dd/yyyy)
*
Gender
<None>
Female
Male
Child has an IEP or IFSP
Suffix
<None>
Jr.
III
IV
Name of Resource Teacher
*
Grade Level
<None>
T/Th Parents' Morning Out (2 years by Sept. 30)
W/F Parents' Morning Out (2 years by Sept. 30)
MWF Parents' Morning Out (2 1/2 years by Sept. 30)
T/Th Preschool (3 years by Sept. 30)
MWF Preschool (3 years by Sept. 30)
MWF PreKindergarten (4 years by Sept. 30)
M-F PreKindergarten (4 years by Sept. 30)
M-F JrK (Older 4's and Young 5's, 5 by 1/31/25)
*
Allergies
<None>
Eggs
Fish/Shellfish
Medication
Milk
None
Other
Peanut
Sesame
Soy
Tree Nuts
Wheat
Best # during school hour Phone
Asthma
Emergency meds kept at school
Best E-Mail
*
Food Restrictions
*
Siblings Names and Ages
Additional Comments
Student 5
*
Last Name
*
First Name
Middle Name
*
Preferred Name (Name you would like us to use in the classroom)
*
Date of Birth (mm/dd/yyyy)
*
Gender
<None>
Female
Male
Child has an IEP or IFSP
Suffix
<None>
Jr.
III
IV
Name of Resource Teacher
*
Grade Level
<None>
T/Th Parents' Morning Out (2 years by Sept. 30)
W/F Parents' Morning Out (2 years by Sept. 30)
MWF Parents' Morning Out (2 1/2 years by Sept. 30)
T/Th Preschool (3 years by Sept. 30)
MWF Preschool (3 years by Sept. 30)
MWF PreKindergarten (4 years by Sept. 30)
M-F PreKindergarten (4 years by Sept. 30)
M-F JrK (Older 4's and Young 5's, 5 by 1/31/25)
*
Allergies
<None>
Eggs
Fish/Shellfish
Medication
Milk
None
Other
Peanut
Sesame
Soy
Tree Nuts
Wheat
Best # during school hour Phone
Asthma
Emergency meds kept at school
Best E-Mail
*
Food Restrictions
*
Siblings Names and Ages
Additional Comments
Primary Family Information
*
Address Line 1
Address Line 2
*
City
*
State
*
ZIP Code
Parent 1 Information
*
Last Name
*
First Name
*
Relation
<None>
Father
Guardian
Mother
Preferred Name
Suffix
<None>
Jr.
III
IV
Gender
<None>
Female
Male
*
E-Mail
*
Best Phone #
Place of Employment
Alternate Phone
*
Languages Spoken
Is Emergency Contact
How did you hear about ELC
<None>
Church Sign
Flyer Posted in Community
Friend/Family
I'm a MPC Member
Online search
Other
Is Allowed to Pickup
Parent 2 Information
*
Last Name
*
First Name
*
Relation
<None>
Father
Guardian
Mother
Preferred Name
Suffix
<None>
Jr.
III
IV
Gender
<None>
Female
Male
*
E-Mail
*
Best Phone #
Place of Employment
Alternate Phone
*
Languages Spoken
Is Emergency Contact
How did you hear about ELC
<None>
Church Sign
Flyer Posted in Community
Friend/Family
I'm a MPC Member
Online search
Other
Is Allowed to Pickup
Secondary Family Information
*
Address Line 1
Address Line 2
*
City
*
State
*
ZIP Code
Parent 3 Information
*
Last Name
*
First Name
*
Relation
<None>
Father
Guardian
Mother
Preferred Name
Suffix
<None>
Jr.
III
IV
Gender
<None>
Female
Male
*
E-Mail
*
Best Phone #
Place of Employment
Alternate Phone
*
Languages Spoken
Is Emergency Contact
How did you hear about ELC
<None>
Church Sign
Flyer Posted in Community
Friend/Family
I'm a MPC Member
Online search
Other
Is Allowed to Pickup
Parent 4 Information
*
Last Name
*
First Name
*
Relation
<None>
Father
Guardian
Mother
Preferred Name
Suffix
<None>
Jr.
III
IV
Gender
<None>
Female
Male
*
E-Mail
*
Best Phone #
Place of Employment
Alternate Phone
*
Languages Spoken
Is Emergency Contact
How did you hear about ELC
<None>
Church Sign
Flyer Posted in Community
Friend/Family
I'm a MPC Member
Online search
Other
Is Allowed to Pickup
Contact Information (Other than parents)
Contact 1
*
Last Name
*
First Name
*
Relation
<None>
Aunt
Friend
Grandparent
Brother
Uncle
Sister
Caregiver
Father
Mother
Is Emergency Contact
*
Primary Phone
Is Allowed to Pickup
Alternate Phone
PLEASE ENTER IN AT LEAST 2 EMERGENCY CONTACT PEOPLE
Pickup Notes
Contact 2
*
Last Name
*
First Name
*
Relation
<None>
Aunt
Friend
Grandparent
Brother
Uncle
Sister
Caregiver
Father
Mother
Is Emergency Contact
*
Primary Phone
Is Allowed to Pickup
Alternate Phone
PLEASE ENTER IN AT LEAST 2 EMERGENCY CONTACT PEOPLE
Pickup Notes
Contact 3
*
Last Name
*
First Name
*
Relation
<None>
Aunt
Friend
Grandparent
Brother
Uncle
Sister
Caregiver
Father
Mother
Is Emergency Contact
*
Primary Phone
Is Allowed to Pickup
Alternate Phone
PLEASE ENTER IN AT LEAST 2 EMERGENCY CONTACT PEOPLE
Pickup Notes
Medical Contacts
Physician
Physician Phone Number
Finished
Confirmation E-Mail address:
Please press the save button to submit the new student application.
