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Free EarlyLearn and 3-K

Services Available


Get ahead of the crowd and complete our online application. An enrollment specialist will be in contact with you as soon as possible. 

Child's Name*

Child's DOB*

Child’s Gender


Child’s Current Address*

Child’s Current Address Line 2*

Parent/ Guardian's Name*

Parent/ Guardian’s Gender


Parent 1 DOB*

Parent 1 Current Address (if different from above)

Parent 1 Current Address Line 2

Parent/ Guardian Email Address*

Parent / Guardian Phone*

Parent 1 Occupation*

Parent 1 Employer's Name*

Parent 1 Work Address*

Parent 1 Work Address Line 2*

Parent 1 Work Phone*

Method of Transportation*


Parent/ Guardian 2 (Optional)

Parent 2 Gender


Parent 2 DOB

Parent 2 Current Address (if different from above)

Parent 2 Current Address Line 2

Parent 2 Email Address

Parent 2 Primary Phone

Parent 2 Occupation

Parent 2 Employer's Name

Parent 2 Work Address Line 1

Parent 2 Work Address Line 2

Parent 2 Work Number

Parent 2 Method of Transportation


Days Care is Needed*






Are you interested in financial assistance for childcare?


Please include information regarding your child’s and/or family tradition and culture.

Does your child have any allergies should be aware of? Please include the symptoms during contact and emergency techniques. *

Is there any medical diet restriction we should know about? Please attach medical statement from a pediatrician/ doctor. *

Please list any health conditions we should be aware of*

Is your child on a daily medication regimen we should know about *

If yes, please tell us the name, strength, dose and frequency of each medication. *

Emergency Contact Information *

Relationship to Child *


Email Address

Permission to pick up child? *

Emergency Contact 2 *

Relationship to Child *

Phone Number

Email Address 2

Permission to pick up child? *

Is there anyone who should not have access to the child? *

If yes, please list full names below. If no, please type n/a*

Do you give BCLA permission to use photos and/or video of your child for the reasons explained below? *

Do you agree to have your child join us for our daily outside activities? *

Do you agree to BLCA Sleeping policy and arrangement. *

Will you need transportation service for you child? *

If you chose yes, which situation applies to you?

Parent/ Guardian Electronic Signature*

Parent/ Guardian 2 Electronic Signature (optional)

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