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Infant / Toddler Application Form
for the 2010-2011 School Year.

Please submit one form per child.

Have you been with us before?*	Current Family Former Family New Family
This is an ongoing list. Your ideal start date would be:*	(month/year)
Child's Birthday* (Or Due Date.)	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2005 2006 2007 2008 2009 2010
Gender*	Boy Girl Unknown (Not yet born)
Age Group*	6 Weeks - 18 Months 18 Months - 3 Years
Child's Name*	First: Middle: (optional) Last
Name to be used at school
Child's Address*
City, State, zip*	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Parent/Guardian Information
Parent/Guardian Name*	First Name: Last Name:
Relationship to Child*	Please Select Mother Father Step Mother Step Father Aunt Uncle Family Friend Foster Parent Grandmother Grandfather Legal Guardian
Parent/Guardian Occupation
Parent/Guardian E-mail*
Parent/Guardian Home Phone
Parent/Guardian Cell Phone For Emergency Contact
Place of Business
Business Phone For Emergency Contact
Additional Parent/Guardian Information
Parent/Guardian Name	First Name: Last Name:
Relationship to Child	Please Select Mother Father Step Mother Step Father Aunt Uncle Family Friend Foster Parent Grandmother Grandfather Legal Guardian
Occupation
E-mail
Home Address If different from Child's Address
City, State, Zip	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Home Phone
Cell Phone For Emergency Contact
Place of Business
Business Phone For Emergency Contact
Additional Information
Names & Ages of Siblings
Additional Information
Where did you hear about our program?	Web Lincoln Kidz Free Times Word-of-mouth
Optional Sponsor a Child	I (We) would like to contribute an extra $10 each month to help a child who needs financial assistance. (This is a tax-deductible contribution). Thank You.
Assistance	I (We) would like to apply for the Tuition Assitance Program. To qualify, your income must be within the guidelines used by the Free or Reduced School Meals Program. Please call our office at 476-8304 for a form or to discuss emergency circumstances.
Session Information
Choice of Sessions Please register for your ideal schedule, but mark here if you are flexible with days (and/or) times.	I am flexible with days. I am flexible with times. I am flexible with days and times.
Early Morning Session Designed to use before the sessions. (Available from 7:45 - 9:00 AM)
Enter drop off time between 7:45-9:00 AM	Mon: Tue: Wed: Thu: Fri:
Sessions* (Full day includes a nap.)	Morning - M/W/F.............9:00 to 11:30 AM Morning - T/Th.................9:00 to 11:30 AM Morning - M thru F...........9:00 to 11:30 AM Full Day - M/W/F.............9:00 AM to 3:00 PM Full Day - T/Th.................9:00 AM to 3:00 PM Full Day - M thru F...........9:00 AM to 3:00 PM
Late Afternoon Session Designed to extend the 9AM - 3PM sessions (Available until 5:15 PM)
Enter pick-up time between 3:00-5:15 PM	Mon: Tue: Wed: Thu: Fri:
A non-refundable Registration Fee of $50.00 will be billed at the time you accept a spot.

Current families have priority for enrollment. After March 4, applications from new families will be processed based on date of receipt and available spaces remaining.

Confirmation and/or waiting list letters will be sent after March 10th.

Note: Fields marked by an asterisk (*) are required.