Education and Dignity for All We are glad you chose us! And what a wonderful choice you have made! We have got you cover! Fill out an application to get the process started! Please enable JavaScript in your browser to complete this form. - Step 1 of 2Anticipated Start Date *Is your child currently enrolled in a school, learning center, access center, or preschool? If so, please name it. *YesNoIf YES, please name it.Has your child ever attended daycare before? *YesNoPlease list the names of the last 3 daycares your child attended, 1 being the most recent and 3 being the least recent. (Note: UPLIFT contacts centers our students attended prior to admission.) Visual Text Name of Child *Gender *FemaleMaleBirthday *Parent/ Guardian 1 Name *Parent/ Guardian 1 Phone *Parent/ Guardian 1 Email *[email protected]Parent/ Guardian 1 Address (Where Child Lives) *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeState issued ID, passport or driver license Click or drag a file to this area to upload. Parent/ Guardian 2 Name *Parent/ Guardian 2 Phone *Parent / Guardian 2 Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeState issued ID, passport or driver license Click or drag a file to this area to upload. Emergency Contact 1 Name *Full nameEmergency Contact 1 Phone *Phone numberState issued ID, passport or driver license Click or drag a file to this area to upload. UploadEmergency Contact 2 Name *Emergency Contact 2 Phone *State issued ID, passport or driver license Click or drag a file to this area to upload. Emergency Contact 3 NameEmergency Contact 3 PhoneState issued ID, passport or driver license Click or drag a file to this area to upload. CommentNextUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.PreviousSubmit
