Enrollment Interest Form

We would love to take care of your child! Please fill out this form and we will get in touch with you shortly.

Parent/Guardian Name*
Prefix First Last Suffix
Please enter the name(s) of the Parent/Guardian of the child(ren) you want to enroll in the center.
Additional Parent/Guardian Name
Prefix First Last Suffix
Address
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Child 1 - Name*
Child 1 Birth Date*
Child 2 - Name
Child 2 Birth Date
Child 3 - Name
Child 3 Birth Date
Child 4 - Name
Child 4 Birth Date
Child 5 - Name
Child 5 Birth Date
Hours Needed*
- Day Shift
- Evening Shift
Location
- NDLA
- NDLA II
- NDLC
Payment Method*
- Out-of-Pocket Tuition
- Illinois Department of Human Services
Click HERE to check your IDHS eligibility.

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