Next Door - Home of Educare
 
 
 

Enrollment Pre-Application

 

PROGRAM PRE-APPLICATION
(please complete ONE form for each child)
Fields in red are required.
Today's Date:

  

CHILD INFORMATION
Child's Last Name: Child's First Name: Child's Middle Name:
Child's Date of Birth: Child's Age (by September 1):  

 

PARENT/GUARDIAN INFORMATION    
Last Name: First Name: Date of Birth:
Street Address: Home Phone: Cell Phone:
Apt #: City: State: Zip Code:
Email Address: (Required for follow-up)  

Are you employed?: Yes No

Are you in school/training? Yes No

Are you currently homeless?: Yes No Highest level of education?: HS GED College Degree:

Are you living with a friend or family?: Yes No

Are you Pregnant?:  Yes  No     When is your due date?:     Are you a high risk pregnancy?:  Yes  No

 

ADDITIONAL PREQUALIFYING INFORMATION

Parental Status: Kinship      Foster Care      Teen Parent      Single Parent      Two Parent Household

Annual Income (before taxes):

Are you currently receiving public assistance?: Yes No

Are you authorized to receive child care subsidy for this child?: Yes No

Family Size:

Does your child have a diagnosed disability?:  Yes No Do you suspect a disability?:  Yes No
If yes, please list the disability/IEP information? If yes, please list why?

 

PROGRAM OPTIONS
 

 

How did you learn about our program? (please check ONE box):

Radio Ads Flyer WIC Location - Name: Walk In Community Event:

Neighborhood Canvassing Parent Referral - Name: Other:

Do you have other children/family members that are already enrolled in any of our NDF programs?

Yes No If yes, please list name(s):

When is the best time to reach you?:

 

 

Next Door | 2545 N. 29th Street | Milwaukee, WI 53210 | (414) 562-2929

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