Enrollment Request Form

Service Information

Expected Start Date:

If Full-Day or Full-Year, what is the supplemental funding source for the time beyond that funded by PHLpreK?

Provider Information

Site name

Site contact name

Site address

I, as a PHLpreK provider, attest that this child is a resident of Philadelphia, is 3 or 4 years old on September 1, 2017 (and not of kindergarten entry age on September 1, 2017), and has been referred to CCIS to determine eligibility for other services. I confirm that all verification documentation (birthdate and residency) is maintained on file at the site location.

Name of staff

Title

Family and Child Information

Child

First name

Last name

DOB

Parent / Guardian

First name

Last name

Email

Phone number

Cell carrier

By initialing this form, Parents/Guardians of PHLpreK children agree to notify their PHLpreK provider within 15 days ifthe family moves outside the city limits of Philadelphia.

Initials