Step 2

Online Application Form

HaleHanoverPulaski

AMPMAM & PMDrop-in
WebsiteNewspaperReferralReturning familyFlyerOther

* 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.

Family Composition


GuardianFoster Parent1 parent2 parent'sWorkingOther

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

Enrollment Information

BoyGirl

Guardian 1

(if applicable)

Guardian 2

Emergency Contacts ** Contacts must be different than the above guardians. **Must have three emergency contacts.

The following people are authorized to pick-up my child (ren) or be contacted in case of emergency. (Must be 18 or older)

I give permission for First Aid to be administered by an appropriate staff member, to my child (ren): in the event of an emergency. I understand I will be called if my child is ill and needs to be picked up (or an alternate emergency contact, if I cannot 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.

I agree that by submitting this application, I am electronically signing the application.
I,



, solemnly declare that the information I have provided is true and that the documents I am submitting in support of my application are genuine and have not been altered in any way.