Children's Center Enrollment Form

Child's Name

Birth Date

Child's preferred pronouns

Second Child's Name

Second Child's Birth Date

Second Child's preferred pronouns

Parent/Guardian

Parent/Guardian Name

Parent/Guardian's preferred pronouns

Address Line 1

Address Line 2

City

State / Province / Region

Country

Evergreen ID#

Email Address

Home Phone Number

Cell Phone Number

Relationship to Evergreen (check all that apply)

Enrolled Student

Student Planning to Enroll

Evergreen Staff or Faculty

Community Member

Please list parent/guardian affiliated with Evergreen first.

Desired Date of Enrollment

How did you hear about the Children's Center?

Additional information about your child or plans which may affect your child's registration:

Children's Center