Jump Start Learning Center

Enrollment Packet
Child Information
Name: ___________________________________ Date of Birth: _______________ Gender __M __F

Race: ____________ Health Insurance: ____________________ Dental Insurance: _________________________

Medical Conditions: ____________________ Special Needs: ______________________ IFSP/IEP: __Y __N

Notes for Medical Conditions or Special Needs:

Does your family need an interpreter? __Y __N Language Spoken at Home: __________________________

Is anyone Legally Prohibited from contact with the child? (Document Required): __Y __N Name: ________________________

Can you transport your child to and from the center? __Y __N Explain: ________________________________________________

Current DCS Involvement: __Y __N

If yes, explain:
 Primary Adult (Parent, Legal Guardian, Authorized Caregiver, or Legal Responsible Party)
Name: _____________________________ Date of Birth: ______________________ Gender: __M __F

Race: __________________ Medical Insurance: __Y __N

Highest Grade Completed: ________________________ Relationship to the child: ___________________________

Employment Status: _______________________

Check all that apply Email: _____________________________________________________

__Have custody of child
__Lives with applicant Phone Number: _________________________
__Provides Financial Support
__Teen Mother (19 & under) Secondary Phone Number: _____________________

Marital Status Living Address: ________________________________________

__Married ______________________________________________________
__Single Same as mailing address? __Y __N
__Divorced If no, Mailing Address: ____________________________
__Widowed ________________________________________________
__Separated
 Siblings in the Home

First Name Last Name Gender Birthday Race Medical Insurance Disabled

Secondary Adult
Name: ___________________________ Date of Birth: _______________________ Gender: __M __F

Race: _________________ Medical Insurance: ______________________________

Highest Grade Completed: ________________________ Relationship to the child: ___________________________

Employment Status: _______________________

Phone Number: ________________________________ Email: _______________________________________________

 Program Requested

__Infant Program: 6 weeks to 12 months

__Toddlers Program: 12 months to 36 months
__Pre-K Program: 3 years-6 years
__After School Hours Program: All Ages
__Summer Program: All Ages

Parents Signature: ___________________________________________________ Date: ______________________