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Children's Learning Center Application
Blue Room Preschool
Preschool Enrollment is August through May.
Child's Information
First Name
Middle Initial
Last Name
Gender
Female
Male
Age
--Select--
3-4 Years
4-5 Years
Date of Birth
Please check the session that you are enrolling your child for:
3 Year Olds
Tuesday/Thursday
9 a.m. - noon
*Your child must be 3 years old by the first day of the semester to be enrolled in the 3-year-old preschool program.
4 Year Olds
Monday/Wednesday/Friday
9 a.m. - noon
*Your child must be 4 years old by the first day of the semester to be enrolled in the 4-year-old preschool program.
Parent/Guardian Information
First Name
Middle Initial
Last Name
Relationship to Child
--Select--
Parent
Legal Guardian
Other
Please select what applies to you:
MCC Student
MCC Employee
Community Member
Student ID#
Street Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Email
Phone number of where to reach you
Employment Information
Employer Name
Employer Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Employer Phone
Work Schedule (Days and Times)
Not Currently Employed
Are you on financial aid?
Yes
No
If yes, what kind?
Pell Grant
Other
If other, please describe
Do you plan to use financial assistance from Illinois Child Care Assistance Program (CCAP)?
Yes
No
A non-refundable Registration Fee for the Blue Room is $25 per semester (Fall and Spring). Fees must be paid
before
your child’s first day in the Blue Room. All fees and payments are to be paid in Registration (A-258), either in person or over the phone by calling (815) 455-8588. Payments cannot be made through the Lillio app.
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