Little Learners Pre-Registration Form

Today's Date

Which center would you like your child to attend? (You may choose more than one) *

New London (6 wks. - 5 yrs.)

Groton (6 wks. - 5 yrs.)

Taftville (6 wks. - 5 yrs.)

Griswold (3 yrs. - 5 yrs.)

CHILD 1 APPLICANT INFORMATION

Child's Name (#1)

First

Last

Date of Birth *

Gender *

Toilet Trained? *

Yes

No

Working On

Known allergies (write n/a if none): *

Current medications (write n/a if none): *

Has child attended any other childcare? *

Yes

No

If yes, may we contact the provider?

Yes

No

Name and contact information of previous childcare:

Does child have IEP/IFSP? *

Yes

No

Is child receiving education or medical services? *

Yes

No

Are there any behaviors the child struggles with at home? *

Yes

No

If yes, please describe behaviors:

Is child in Foster Care? *

Yes

No

CHILD 2 APPLICANT INFORMATION

Child's Name (#2)

First

Last

Date of Birth

Gender

Toilet Trained?

Yes

No

Known allergies (write n/a if none):

Current medications (write n/a if none):

Has child attended any other childcare?

Yes

No

If yes, may we contact the provider?

Yes

No

Name and contact information of previous childcare:

Does child have IEP/IFSP?

Yes

No

Is child receiving education or medical services?

Yes

No

Are there any behaviors the child struggles with at home?

Yes

No

If yes, please describe behaviors:

Is child in Foster Care?

Yes

No

Working On

ADULT 1 INFORMATION

Name *

First

Last

Date of Birth *

Employment *

Primary Language *

ADULT 2 INFORMATION

Name

First

Last

Date of Birth

Employment

Primary Language

FAMILY CONTACT INFORMATION

Address *

Address

Street

Apartment/Unit

City

State/Province

Zip/Postal

Country

Phone *

Email

Are you a TVCCA client? *

Yes

No

If yes, which program(s)?

Do you receive TFA? *

Yes

No

Is family DCF involved? *

Yes

No

If yes, name and contact info of DCF Worker:

Apply Today

CHILD 1 APPLICANT INFORMATION

CHILD 2 APPLICANT INFORMATION

ADULT 1 INFORMATION

ADULT 2 INFORMATION

FAMILY CONTACT INFORMATION

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