Intake Application

The Enrollment Process
The Intake Application is the first step to getting your child enrolled for services at Children Inc. Learning Center. After you submit the intake application, you will be contacted to complete the rest of the enrollment packet. If there is an enrollment wait list for your child’s age, we will tell you at the time your are contacted. If you don't want to fill out this form online you can download the application and fill it out by clicking here.

Admission Policy
The center will accept children who are six weeks through age twelve (12)/ or sixth grade. The center will admit and serve any child as long as the center is capable of meeting a child’s needs and the child is not a danger to other children in the center. There will be no discrimination on the basis of race, color, religion, sex national origin, or disability.

Child's Info

Name of person(s) legally responsible for the account

Date of Admission

Gender

Male
Female

Child's name

Child's nickname

Date of Birth

Current age

Verification Document (i.e. birth certificate)

You can upload your verification document here or you can bring it with you on your first visit.

Click or drag a file to this area to upload.

Child's home address

Mother's Info

Mother's name

Mother's Phone

Mother's Email *

Mother's home address

Address Line 1

City

State

Zip Code

Mother's Employer name

Mother's Employer Phone

Father's Info

Father's name

Father's Phone

Father's Email *

Father's home address

Address Line 1

City

State

Zip Code

Father's Employer name

Father's Employer Phone

Other info

Other children in family

Birth date

Age

Grade/School

Other children in family 2

Birth date 2

Age 2

Grade/School 2

Other children in family 3

Birth date 3

Age 3

Grade/School 3

I give consent for my child to be photographed for classroom and/or marketing purposes

By clicking on the Submit button you confirm that all the information entered is accurate and correct to the best of your knowledge.