Waiting List Form | Empower Learn Create

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About
Locations
- Empower Learn Create at UC
Employment
Tuition
- Empower Learn Create at UC Tuition
Waiting List
Quick Links
Donate

Waiting List Formearlylearning2024-03-27T11:52:54-04:00

Waiting List Application

ELC is committed to serving a diverse population of children and families in our program. Please fill out the application below to get on the waitlist. For more information on our Waiting List Policies & Procedures click on the link below.

Waiting List Policies & Procedures

Waitlist Application - No NKU

Note: There is a $55 (non-refundable) registration fee

"*" indicates required fields

PERSONAL INFORMATION

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Are you a student?*

Yes

No

If yes, name of school:*

Please provide your UCID (beginning with M) or your NKU Card Number*

Are you employed at UC or NKU?*

Yes

No

If no, list place of employment*

Please provide your UCID (beginning with M) or your NKU Card Number*

DETAILS OF CARE NEEDED

Date of care needed*

MM slash DD slash YYYY

Type of care needed*

Full Time

Part Time

Preferred Site*

Empower Learn Create at UC

Child's Name*

Child's Date of Birth*

Do you have more than one child needing care?*

Yes

No

(If yes, please fill out 1 form per child. The $55 registration fee is due for each child)

FINANCIAL ASSISTANCE

Do you qualify for any type of assistance?*

Yes

No

If yes, what type of assistance?*

Registration Fee

Price:

Credit Card*

Card Details

Cardholder Name

info@empowerlearncreate.org
(513) 961.2825

Empower Learn Create at UC

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