Child and Family Life Education Center (CFLEC) Enrollment Form

Submit this form to request your child's enrollment in EIU's CFLEC for Fall 2024.

Cost of Attendance: $100 per child/per semester.

Children eligible for enrollment must be 3 years of age as of September 1st (Fall Semester) and January 1st (Spring Semester) and can continue until they are eligible for kindergarten.

Attendance is on Tuesdays and Thursdays from 9:00am to 11:00am.
Fall 2024 Dates:
Start:
End:
Will not meet:

Parent/Guardian Name: Parent/Guardian Name: * First Last
Cell Phone Number: Cell Phone Number: * - ### - ### ####
Email: *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Child's Name: Child's Name: * First Last
Child's Date of Birth: Child's Date of Birth: * / MM / DD YYYY
Upload Copy of Child's Birth Certificate: *

Attach Files
Please list anything you would like to share about your child: (allergies, injuries, toileting habits, favorite activities)
Transportation:

List of individuals who are authorized to transport child to and from the CFLEC on a regular basis. (As situations arise, ask to add or delete names from the form in the child’s file).
#1 Transportation - Name: #1 Transportation - Name: * First Last
#1 Transportation - Phone Number: #1 Transportation - Phone Number: * - ### - ### ####
#1 Transportation - Address #1 Transportation - Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
#2 Transportation - Name: #2 Transportation - Name: First Last
# 2 Transportation - Phone Number: # 2 Transportation - Phone Number: - ### - ### ####
# 2 Transportation - Address: # 2 Transportation - Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
#3 Transportation - Name: #3 Transportation - Name: First Last
#3 Transportation - Phone Number: #3 Transportation - Phone Number: - ### - ### ####
#3 Transportation - Address: #3 Transportation - Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
ENROLLMENT ACKNOWLEDGEMENT:

By submitting this form, I understand that this facility is a University practicum laboratory. As participants in this program, the children will interact with University students under the close supervision and guidance of a member of the Human Services Department faculty.

By submitting this form, I consent to digital still, video, and audio recording/photography to be used for documentation of classroom activities and for academic instruction and research purposes. Occasionally WEIU, the Daily Eastern News, and EIU staffing will take photographs/videos of the children which can used on platforms such as television, newspapers, websites, and Facebook. When this occurs, the children will not be identified by name.

By submitting this form, I understand the policy that no child will be released to an individual whose name does not appear on this form unless prior consent to the Director has been given via telephone or written communication by the parent/guardian. A driver's license or photo ID will be required of individuals unknown to staff.

By submitting this form, I understand the aspects of the program described above. This form replaces every enrollment form previously submitted for this facility, and shall be in effect until your child is discharged from the Eastern Illinois University Child and Family Life Education Center.
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Child and Family Life Education Center (CFLEC) Enrollment Form

Child and Family Life Education Center (CFLEC) Enrollment Form

Transportation:

ENROLLMENT ACKNOWLEDGEMENT: