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Early Childhood Center Application

Please fill out the application below for admission to the Temple Emanuel

Early Childhood Center. This application, when accompanied by your $100.00

non-refundable application fee, will ensure consideration for next year’s

program.

The key to our success is communication between you, your child’s teacher, and

school administrator. As director of the Early Childhood Center, I look forward

to meeting with you.

Sincerely,

Stacy Kesner, M.A.

Early Childhood Center Director

* Child's Name

* Child's Date and Place of Birth

* Home Address

* Home Telephone

Parent 1 Information

* Name

* Cell Phone #

Home Address (if different from child)

Home Phone (if different from child)

* Occupation

Other Children/Siblings of child

Please include names, ages, and schools

Parent 2 Information

Name

Cell Phone #

Work Phone #

Email Address

Home Address (if different from child)

Home Phone (if different from child)

Talking Points

* What language(s) are spoken at home?

* Does your child have special needs?

* Please describe all illnesses, allergies, and medications your child has:

* What family activities does your child enjoy?

* What are your child's favorite games and interestes?

* How much television does your child watch?

* Does your family have a pet? What kind?

* Has your child had formal group experience?

Examples: parent and me classes, gym classes, swimming lessons, etc. Please list all programs.

* What are your expectations for your child in our Early Childhood Center?

* Why did you choose to apply to our Early Childhood Center?

* How did you hear about our Early Childhood Center?

* Application Fee:

One Application

$100.00

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Help your contribution go further. Please use your checking account rather than a credit card for online payment. This saves Temple Emanuel credit card processing fees. Or please increase your contribution by 3% to cover our fees.

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