Step 2 - Women & Families Center (WFC) in Connecticut

Online Application Form

Child's Name*

Parent/Guardian's Name*

Parent/Guardian Phone Number*

Email Address*

Hanover Elementary School

6:45 am to 8:45 am

3:20 pm to 5:30 pm

Nathan Hale Elementary School (M-Th)

6:45 am to 8:45 am

3:20 pm to 6:00 pm

Nathan Hale & Pulaski

Close at 5:30 on Fridays

* Please provide the following information about your child/family. It is required for statistical purposes only because our agency receives state funds. It does not affect your admission to our program in any way.

The following are all required. Return completed form with documents to the Program Manager. Incomplete applications will not be processed.

Enrollment Information

Enrollment Date*

Child’s FirstName*

Child’s LastName*

D.O.B

Age*

Race

Social Sec. #

Gender BoyGirl

Address*

City*

State*

Zip-Code*

Health Insurance information

Insurance Company

Primary Doctor’s Name*

Doctor’s Telephone #*

Dentist’s name*

Dentist’s Telephone #*

Guardian 1

Relationship to child*

Last name*

First name*

Address*

City*

State*

Zip-Code*

Home Tel. #*

Cellular #

Place of Employment

Address of Employment

Phone Number

If have no employment information are you:

Self-EmployedUnemployment

Guardian 2 (if applicable)

Relationship to child

Last name

First name

Address

City

State

Zip-Code

Home Tel. #

Cellular #

Place of Employment

Address of Employment

Phone Number

If have no employment information are you:

Self-EmployedUnemployment

I give permission for First Aid to be administered by an appropriate staff member to my child: in the event of an emergency/ I understand that I will be called if my child is ill and needs to be picked up (or an alternate emergency contact if I can not be reached) I grant permission for my child to be transported to a hospital by emergency vehicle and to receive emergency medical treatment, at any medical facility if I am not able to be present.

Parent/Guardian Signature:

Date:

The Following information is used to help determine which level you will fall into for our tuition rates:

Family Composition

How many family members live in the home including the child:

How many family members
are adults:

How many family members
are children:

How many family members are grandparents:

How many family members are Aunts or Uncles:

Unrelated persons (ex, partner, spouse, significant other, step children)

Child primarily resides with:Parent/Guardian 1Parent/Guardian 2BothShared 50/50

Parent/Guardian Signature:

By signing I am saying that all the above information is accurate as of date of enrollment.

Emergency Contacts
** Contacts must be different than the above guardians.**
*** 3 different emergency contacts are required.***

The following people are authorized to pick-up my child (ren) and be contacted in case of emergency.

(Must be 18 or older)

1. Name*

Relationship to child*

Address*

License / ID. #

Tel:#*

Alternate Tel #

2. Name*

Relationship to child*

Address*

License / ID. #

Tel:#*

Alternate Tel #

3. Name*

Relationship to child*

Address*

License / ID. #

Tel:#*

Alternate Tel #

I understand that if another individual comes to pick up my child that is not listed on this form, they will not be able to take the child. You may add other pick up people at any time via a note given to the program manager.

Online Application Form

Contact Form