Children's Center Enrollment Form

Child's Name *

Birth Date *

Year

Month

Day

Child's preferred pronouns

Second Child's Name

Second Child's Birth Date

Year

Month

Day

Second Child's preferred pronouns

Parent/Guardian

Please list parent/guardian affiliated with Evergreen first.

Parent/Guardian Name *

Parent/Guardian's preferred pronouns

Evergreen ID#

Email Address *

Cell Phone Number

Relationship to Evergreen (check all that apply) *

Enrolled Student

Student Planning to Enroll

Evergreen Staff or Faculty

Community Member

Desired Date of Enrollment

Year

Month

Day

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