EmailMeForm
Early Learning Programs Pre-Enrollment Form
Centralia College does not discriminate against any person on the basis of race, color, national origin, disability, sex, genetic information, or age in admission, treatment, or participation in its programs, services and activities, or in employment. All inquiries regarding compliance with access, equal opportunity and/or grievance procedures should be directed to the Vice President of Human Resources and Equity, Joy Anglesey, Centralia College, 600 Centralia College Blvd, Centralia, WA 98531, 360-623-8943, or joy.anglesey@centralia.edu.
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Child's Name
*
First
Last
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's Gender
Boy
Girl
Email
*
Parent/Guardian #1
Complete the information below for parent/guardian #1.
Parent/Guardian #1 Name
First
Last
Birthdate
MM
/
DD
/
YYYY
Phone
*
###
-
###
-
####
Can we send text messages?
*
Yes
No
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Employer
College & Major
How many hours per week do you spend working or going to school?
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