Early Childhood Learning Center Request Form

Program Director
Sonya Evariste
(718) 482-5217
sevariste@lagcc.cuny.edu

Child Care Request Form

Please fill out the Child Care Request Form. All fields are required.

Name(Required)

First Last

Home Phone(Required)

Cell Phone(Required)

Address(Required)

Street Address City State ZIP Code

Email(Required)

Home Language(Required)

Other Languages

Gender(Required)

Financial Aid Eligible(Required)

ASAP Eligible(Required)

Ethnicity(Required)

Marital Status(Required)

Other Status (please specify)(Required)

Child’s Full Name(Required)

Child's Date of Birth(Required)

Age(Required)

Gender(Required)

Student Type(Required)

Major / Degree(Required)

Empl ID(Required)

Add Non-Degree(Required)

CUNY College Name(Required)

Which of our program are you requesting for your child? (Please check all that apply):(Required)

Infant (12 mos–23 mos)

Toddler (24 mos–33 mos)

Preschool (2.10–4 years)

Pre-K For All (4 years only)

Extended Day (5–12 years)

Saturday Program (3–12 years old)

Summer Camp (3–12 years old)

Holiday Camp (5–12 years old)

Signature(Required)

Date(Required)

Name

This field is for validation purposes and should be left unchanged.