<p> Please return this form to the TCC Early Learning Center. *Completion of this form does not guarantee enrollment.*</p><p>Parent/Guardian Name: ______Date: ______Home Address: ______City: ______State: ______Zip: ______Phone: ______TCC Email: ______Alternate Email: ______</p><p>Language Spoken? Primary: ______Secondary: ______Interpreter Needed? □ No □ Yes </p><p>□ Faculty/Staff □ Community Member □ Sibling currently enrolled at this center □ Past TCC Student □ Full-time TCC Student (10 credits or more) □ Part-time TCC Student (9 credits or less) □Future TCC Student</p><p>Student I.D. # ______</p><p>Quarter & Year you prefer to begin care? ______(Does not guarantee enrollment) Are you currently receiving a DSHS Childcare Subsidy? □ No □ Yes, Part-time Subsidy □Yes, Full-time Subsidy If not – Do you think you may qualify as a low income family? □ Yes □ No (To apply for DSHS Subsidy call 1-877-501-2233) Monthly childcare cost will be paid by: □ Self Pay □ DSHS Childcare Subsidy □ Tribal Assistance Check all that apply: □ Homeless □ Child in Foster/CPS Care □ Receiving TANF CASH □ Transfer from current EHS/ECEAP/HS program □ Child receiving SSI □ Parent receiving SSI</p><p>Child’s Name: Age: Birthdate/Due date: Walking? Male/Female:</p><p>Before your child starts, you will need to bring in: o Immunization Records/Exemption Letter o SNAP Number/Basic Food/FDPIR o Current Well-Child Exam o Parent/Guardian ID o Current Dental Exam o IEP, if needed o Medical Insurance # o Allergy Plan, if needed My signature acknowledges that I am responsible for updating my information with the TCC ELC: As of October, 2017 Parent’s Signature: ______Date: ______</p><p>For questions about enrollment or any updates to your contact information, please email our Program Assistant, Angela Wheeler at: [email protected] </p><p>Admission Policy: In order to enroll your child, you must complete all registration forms, including: current immunization records, a physical exam by a health care professional, and an orientation at the TCC ELC. A prepaid, non-refundable, $100.00 registration fee is required before enrollment to reserve a spot for your child. We will call or email you when we have a space for your child. DO NOT PAY BEFORE WE CALL YOU. (DSHS, ECEAP, and EHS families do not need to pay this fee).</p><p>Approximately 40% of children enrolled must qualify for ECEAP/Early Head Start (which are state and federally funded programs for low income families). For questions about these low income programs, please email Christine Caro, Family Support Specialist at [email protected] </p><p>If your child is already at the ELC and continuing with us next quarter/year, you do not need to reapply.</p><p>Other considerations for Waiting List applications:  There is a spot in the age-appropriate classroom for your child  You already have a child in our program (sibling)  You are a student at TCC  You are a faculty or staff member at TCC  There is a referral from CPS</p><p>**Please either make or request a copy of this document for your records.**</p><p>------</p><p>As of October, 2017</p>