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    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
    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

    TFACCAPJobs FirstOther

    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

    Self-EmployedUnemployment

    Guardian 2 (if applicable)

    Self-EmployedUnemployment

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

    Family Composition

    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)

    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.


    WFC Before & After School Program

    ENROLLMENT INFORMATION FOR CHILDREN

    Child’s Name

    BoyGirl

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

    Date

    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,

    , 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.

    Name of child*

    Program*

    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.

    Name of child*

    Program*

    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.

    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
    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.

    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.