Enrollment Form

Recognizing that early childhood is a critical period of human development that lays the foundation for future learning and also recognizing the essential role families play in this process, it is the mission of Education Partners Early Learning Academy to engage Parents as partners in their child ’s care and education. Read more

The Early Learning Academy... Enrollment Form

All fields with an asterisk must be filled out ( * )

	Mother's Information		Father's Information
Mother^*		Father^*
Primary Address^*		Primary Address ^*
City & Zip ^*		City & Zip^*
State^*		State^*
Home Phone ^*		Home Phone ^*
(include area code)		(include area code)
Cell Phone ^* (include area code)		Cell Phone ^* (include area code)
E-mail ^*		E-mail ^*
Mother’s Occupation/Title^*		Father’s Occupation/Title ^*
Employer's Name ^*		Employer's Name ^*
Employer's Address^*		Employer's Address^*
City & Zip^*		City & Zip^*
State^*		State^*
Work Phone (include area code)		Work Phone (include area code)
E-mail		E-mail
Schedule: Days/Hours ^*		Schedule: Days/Hours ^*

	Child's Information
Child's First Name ^*		M.I.^*	Last^*
Date of Birth (mm/dd/yyyy) ^*
Has child had a physical within the last 3 months? ^*
Are Immunizations up to date and documented?^*
Family Structure: (With whom does the child live?) ^*
Questions or Other information you would like us to know:

Directions to The Early Learning Acacemy