Enrollment Interest Form 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Child 1 - Name* Child 1 Birth Date*Child 2 - Name Child 2 Birth DateChild 3 - Name Child 3 Birth DateChild 4 - Name Child 4 Birth DateChild 5 - Name Child 5 Birth DateHours Needed* Day Shift Evening Shift LocationNDLANDLA IINDLCPayment Method* Out-of-Pocket Tuition Illinois Department of Human Services Click HERE to check your IDHS eligibility.