Enrollment Form - Leech Lake Early Childhood Development

Child's Name *

Date of Birth *

Please check *

I understand that completing this enrollment packet does not guarantee my child/ren a spot in the program.

I understand that my child/ren's enrollment packet cannot be scored without providing income verification.

I understand that I am responsible for notifying the Leech Lake Early Childhood Program with any changes to my contact information. This also includes pick up drop of information for Head Start children.

I understand that enrollment packets must be completed yearly. This includes children on the waiting list.

I understand He A, MMR, and Varicella are required immunizations for my child/ren to be eligible to attend the Leech Lake Early Childhood program. If a child already in the program becomes old enough to receive these Immunizations and the parent fails to do so the child may be suspended.

I understand that if a parent chooses not to immunize their child whether for medical or non-medical reasons they MUST sign an exemption notary form.

Information Needed

Income Documentation

Date Submitted

Comments

Birth Certificate

Date Submitted

Comments

Well Child Exam

Hemoglobin (between 9~2 months)

Lead (12 & 24 months)

Date Submitted

Comments

Immunizations

Date Submitted

Comments

Dental (Over 12 months)

Date Submitted

Comments

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