Waiting List Form

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

Waiting List Formearlylearning2021-06-30T08:28:53-04:00

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

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

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

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

Empower Learn Create at NKU

Child's Name*

Child's Date of Birth*

Do you have more than one child needing care?*

Yes

(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

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

About
Tuition Rates for ELC at UC
ELC at UC Financial Assistance

Empower Learn Create at NKU

About
Tuition Rates for ELC at NKU
ELC at NKU Financial Assistance

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