KEO

Early Learning Centers Application

Center Applying for (Please check)
______Kalaheo Early Learning Center
______Full Time
______Part Time
______a.m.
______p.m.

______Lihue Early Learning Center

______Full Time
______Part Time
______a.m.
______p.m.

Date Requested:

____________________
Mo.
Day
Year

to

_____________________
Mo.
Day
Year

Childs Name:

________________________________________________________________________
Last
First
Middle

Childs Birthdate:

_____ _____ _____ ______________________

Mo. Day Year
Place

Child Resides with:

________________________________________________________________________
Name/Relationship

Mailing Address:

________________________________________________________________________

Resident Address:

________________________________________________________________________

__________________________
Day Contact Number

______________________________
Birth Certificate #

_____________________________
Home Number

Family Background
__________________________________________________________________________________________
Mother Name
Mailing Address
Hm. Phone #
__________________________________________________________________________________________
Occupation
Employer
Work Phone #
__________________________________________________________________________________________
Fathers Name
Mailing Address
Hm. Phone #
__________________________________________________________________________________________
Occupation
Employer
Work Phone #
Person(s) Responsible for Tuition Payment_______________________________________________________
(If different from Father/Mother please list phone number.)
For Office Use Only
Date Registration fee submitted_________________

Date of Enrollment____________________
For ELC Use Only

Date Received by Center_____________________ Form 14 Completed __________________ TB Completed ___________________

REV. 4/20/10