State Application Form

* = Required Information

Child's Name *

Gender *

Male

Female

Date of Birth *

Age *

Ethnicity *

Parent Name *

Home Address *

City

State

Zip Code

Phone * - -

Email *

Employer (Agency/Organization)

Parent/Guardian Name

Home Address

City

State

Zip Code

Phone - -

Employer (Agency/Organization)

Desired start date

Please check one:

Full Time

Part Time

Please note what hours of care you will need.

Does your child speak English?

Yes

Does your child have previous school experience?

Yes

School Name

Phone - -

Does your child have special needs and require special accommodation? If so, please explain:

A $115 nonrefundable application fee must accompany this application. All information will be kept confidential. A completed medical form is required before enrollment at the Center.

Parent/Guardian Signature *

Clear

Date Signed

(for those employed by New York State) Amount: