Richland Application For Enrollment Form PDF Details

Are you considering applying for enrollment at Richland, but not sure where to start? Don't worry – we've got you covered! This blog post will walk you through the necessary steps to fill out a successful Richland application for enrollment form. We'll provide helpful tips and discuss important aspects of the application process so that your submission is quick and simple. By taking the time to do it right, you can be one step closer to joining the dynamic community here at Richland!

QuestionAnswer
Form NameRichland Application For Enrollment Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesenrollment_app college application to print form

Form Preview Example

Application for Enrollment

The Adele P. Glen Academy for Early Childhood Education Academy

Richland Community College | One College Park | Decatur, Illinois 62521

Date

All information is confidential. We cannot share in any information you provide without your written permission.

Child’s Name

Last

First

M.I.

Birthdate

Sex

Parent/Guardian’s Information

Last

First

RCC ID #

 

 

 

Home Address

 

 

 

 

 

City

State

Zip

 

 

 

Home Phone

Cell Phone

Work Phone

Place of Employment

Last

First

RCC ID #

 

 

 

Home Address

 

 

 

 

 

City

State

Zip

 

 

 

Home Phone

Cell Phone

Work Phone

 

 

 

Place of Employment

 

 

Primary Custodian/s: Mother

Father

Legal Guardian

Married Parents

Is non-custodial parent allowed to access or pickup child?

Yes

No

 

If yes, list name of non-custodial parent:

 

 

 

 

Emergency Contacts

Please list two people to contact if Parent/Guardian cannot be reached

Last

First

Relationship to Child

 

 

 

Street Address

 

 

 

 

 

City

State

Zip

 

 

 

Home Phone

Cell Phone

Work Phone

Last

First

Relationship to Child

 

 

 

 

Street Address

 

 

 

 

 

 

 

City

State

Zip

 

 

 

 

Home Phone

Cell Phone

Work Phone

Physician to Contact

Physician’s Name

Phone Number

Address

Hospital or Clinic

Health of Child

Please explain any of the following that concern your child. Mark ”no” or ”none” if your child does not have any of the below conditions.

Do not leave blank.

Medical Conditions

Physical Handicaps

Restrictions for Play

Allergies

Asthma

Food Likes

Food Dislikes

Fears

Is your child toilet trained? Yes No

Does your child have special names for common objects? (potty, cookies, drinks, etc.)

Does your child take medications regularly?

 

If so, what kind and frequency

 

 

 

 

Other information that you feel would be helpful

What program option are you interested in?

5 days a week

3 days a week 2 days a week

 

Parent/Guardian Signature

 

 

 

 

 

 

 

 

 

 

 

Signature of Parent/Guardian

Date

Signature of Director

Date

Signature of Parent/Guardian

Date