Child Information
Child's First Name

Child's Last Name

Child's Date of Birth (mm/dd/yy)

Does your child attend preschool at the ELC?

Parent/Guardian #1
First Name

Last Name

Email Address

Phone Number

Street Address

Street Address, Line 2

City

State

Zip

Parent/Guardian #2 (Optional)
First Name

Last Name

Email Address

Phone Number

Street Address (if different)

City (if different)

State (if different)

Zip (if different)

Additional Family Information
How did you hear about us?

Religious Affiliation

Is there anything else you'd like us to know?