Child's Name *

First Name

Last Name

Child's Date of Birth or Expected Due Date *

MM

DD

YYYY

Preferred Start Date *

MM

DD

YYYY

Preferred Schedule *

5 days/week (Monday-Friday)

3 days/week (Monday, Wednesday, Friday) (not offered in infant program)

2 days/week (Tuesday, Thursday) (not offered in Infant program)

Please select *

Full days

Half days

Parent/Guardian's Name (#1) *

First Name

Last Name

Parent/Guardian's Home Address (#1) *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian's Phone Number (#1) *

(###)

###

####

Parent/Guardian's Name (#2)

First Name

Last Name

Parent/Guardian's Home Address (#2)

(If different)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian's Phone Number (#2)

(###)

###

####

Will your family seek financial assistance through the Illinois Child Care Assistance Program? *

Yes

No