Enrollment Pre-Application

 NEXT DOOR - EDUCARE
PRE-APPLICATION

 Today's Date:  

STUDENT INFORMATION
Child's First Name:     Child's Last Name: 

Date of Birth: 

Age:
 0-1 Years of Age  1 Year of Age  2 Years of Age  3 Years of Age  4 Years of Age  5 Years of Age  6-16 Years of Age

Gender:  Male Female    Child has diagnosed disability:  No Yes

Language spoken in the home:  English Hmong Spanish Other

PARENT/GUARDIAN INFORMATION
Parent's First Name:    Parent's Last Name: 

Street Address: 

City:    Zip Code: 

Phone Number: 

Work Phone:                      Cell Phone: 

Email Address: 

I currently receive the following benefits: 
 Child Care Subsidies  Kinship Care  W-2

Annual Income:                    Family Size: 
(before taxes)

PROGRAM OPTIONS
 Full-day - Infant Care (6 weeks to 24 months)
 Home-based Early Head Start (birth - 3 years)
 Home Based Head Start (3-5 years)
 Full-day - Toddler Care (2 year olds)
 Full-day - Head Start  (3 year olds)
 A.M. Half day-Head Start (3 year olds)
 P.M. Half day-Head Start p.m. (3 year olds)
 Full day-MPS K-4
 Full day-MPS K-5 
 After School Program (6-16 years)

HOW DID YOU LEARN ABOUT NEXT DOOR
 Radio  Television  Open House at Next Door  Community Event  Blue Book  Red Book  Lena's Food Store Billboard Website  Donor  Other

I WAS REFERRED BY A PARENT?  No Yes

PARENT'S NAME: 

Thank you for completing the Pre-Application.  A member of Next Door/Educare's Family Support Team will contact you soon regarding next steps in the enrollment process.

If you have any follow-up questions, please click here and send us an email.

Thanks again,

Next Door/Educare Staff