Early Childhood
Pre-enrollment Signup

Welcome to the OLHSA Early Childhood Pre-enrollment signup form. Your privacy is important to us - This form is securely sent to us and stored securely.

Child's First Name
Child's Last Name
Child's Date of Birth
Month - Day - Year
Your First Name
Your Last Name

Address

Street Address
Street Address 2
City	State
Postal Code	Country

Phone
Area CodePhone Number
Email
Total Number in Household
Estimated annual total household income
Bring documentation to first appointment
Do you currently receive public assistance (SSI, SNAP or FIP/cash)?
Yes
No
Are you currently homeless?
Yes
No
Are you enrolling a foster child?
Yes
No
Does your child have an IEP/IFSP?
Yes
No
I Certify that all of the foregoing statements are true and correct to the best of my ability.
Signed
Full Name
Datetime
Month / Day / Year
Captcha

Early Childhood Pre-enrollment Signup

Early Childhood
Pre-enrollment Signup