test - Women & Families Center (WFC) in Connecticut

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WFC Before & After School Program

ENROLLMENT INFORMATION FOR CHILDREN

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Child’s Name

Last Name

First Name

D.O.B

Age

Race

Social Sec. #

Address

City

State

Zip-Code

Gender *BoyGirl

Health Insurance information

Insurance Company

Primary Doctor’s Name

Doctor’s Telephone #

Dentist’s name

Dentist’s Telephone #

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I agree that by submitting this application that I am signing this application.

, 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.

Date

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Signature of Parent/Guardian*

Date:*

Signature of Witness*

Date:*

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If you do not want to provide proof of income, please read and sign below.

As part of the enrollment process, we require parents/guardians to provide us with proof of income. If you do not want to provide us with proof of all income information, you will be automatically placed on the highest tuition level which is Level 3.

WFC receives grant funds that require us to do statistical reports. Income information is used for this purpose as well as determining your weekly tuition rate. By being be placed in our Level 3 bracket you will also be waiving eligablility for any financial assistance the Women and Families Center may be offering. You are still eligible to apply for Care 4 Kids.

Name of child*

Program*

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

Parent/Guardian’s Signature*

Date*

, 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.

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Name of child*

Program*

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

Parent/Guardian Signature*

Date*

, 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.

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Name of child*

Program*

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

Signature*

Date*

, 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.

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I do give permission for my child (print name),I do not give permission for my child (print name),
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to be photographed by the staff of the WFC. I understand my child’s photo may be used for displays, brochures, advertising, or other forms of marketing, and educational purposes.
OR
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to be photographed by the staff of the WFC. I understand my child’s photo will not be used for displays, brochures, advertising, or other forms of marketing, and educational purposes.
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I agree that by submitting this application, I am electronically signing the application.
I,

Parent/Guardian Signature*

Date*

Parent/Guardian Email*

Site Manager Signature*

Date*

Site Staff Signature*

Date*

, 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.

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WFC Before & After School Program

ENROLLMENT INFORMATION FOR CHILDREN

If you do not want to provide proof of income, please read and sign below.

Contact Form