Parent *

First Name

Last Name

Parent DOB *

MM

DD

YYYY

Parent Hispanic? *

Yes

No

Parent Contact

(###)

###

####

How did you hear about Morning Glory? *

www.mgelc.com

Open House

School Readiness Referral

Online Ad

Friend/Family Member

Mailing

Supermarket Table

Phone Call

211

Secondary Care Giver

Only fill out if this person can be contacted for emergencies or will be a pick up person.

First Name

Last Name

Secondary Care Giver DOB

Date of Birth to confirm ID to pick child up.

MM

DD

YYYY

Secondary Care Giver

(###)

###

####

Days Needing Childcare *

Monday

Tuesday

Wednesday

Thursday

Friday

Child *

First Name

Last Name

Child DOB *

MM

DD

YYYY

Child Hispanic? *

Yes

No

Does your child have a disability? *

Yes

No

My child has an IFSP* or IEP *

*Individual Family Service Plan is a plan for special services for young children with developmental delays.

Yes

No

My child has or is receiving mental health treatment. *

Yes

No

Service(s) I receive:(if yes, provide # or documentation) *

You can submit documentation using the first link multiple times, if needed.

Food Stamps

SNAP

WIC

TANF

None

Right now I work *

Employed Full-time

Employed Part-time

Job Training or in School

Unemployed

Member of US Military on Active Duty

I am a US Veteran *

Yes

No

The father/father-figure is engaged in childcare activities at the center *

Yes

No

I am disabled *

Yes

No

Phone *

(###)

###

####

Child's DOB *

MM

DD

YYYY

Parent (self) *

First Name

Last Name

Child *

First Name

Last Name

Family Member 3

First Name

Last Name

Family Member 4

First Name

Last Name

Family Member 5

First Name

Last Name

Family Member 6

First Name

Last Name

Family Member 7

First Name

Last Name

Family Member 8

First Name

Last Name

Do you receive any government assistance?

This can qualify you for further tuition reduction.

SNAP

Food Stamps

TANF

SSI

Other