OLHSA 
Early Childhood Pre-Enrollment
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 in an encrypted manner.
*Required Fields
Child's Date of Birth*
RadDatePicker
RadDatePicker
Open the calendar popup.
 
Child's First Name*  
Child's Last Name*  
 
Your First Name*  
Your Last Name*  
 
Address*   Apt #
City*   Zip
 
Phone*  
Email*  
Total number in household:
select
Estimated annual total household income $
Bring documentation to first appointment
Do you currently receive public assistance (SSI or FIP/cash)?
select
Are you currently homeless?
select
Are you enrolling a foster child?
select
Does your child have an IEP/IFSP?
select
 

Education
 Name & Location of schoolLast year completed Did you graduate?Subjects studied and Degree(s) received
Grammer School
select
select
High School
select
select
College
select
select
 
Ethnicity - Language
Primary Language Spoken
select
Ethnicity
select
Race
select
 
Miscellaneous
Do you have any Children?
select
Are you currently pregnant?
select
Are you an expectant father?
select
Attending Summer School?
select
         If yes, Where?
        What days/times
         School contact person and phone
If  you will be playing sports in the fall will you begin practice in august?
select
Have you participated in the Free lunch program at school within the
last year? If yes, what school
Do you have reliable transportation to get to and from olhsa several times a week?
select
 
 
 

I Certify that all of the foregoing statements are true and correct to the best of my ability.
[Signed]
Full name:
  6/26/2017