ELRA Enrollment Form Parents to apply for Infant and Toddlers Program, and NON-Camden residents. Please fill out application below. Step 1 of 3 33% Child InformationInclude up to 3 children.Child 1Child's Name* First Last Date of Birth* MM DD YYYY Child's Age as of 10/2019*Gender*MaleFemalePrimary Language Spoken at Home*Current/Previous Pre-School Provider*Child 22nd Child's Name First Last Date of Birth MM DD YYYY Child's Age as of 10/2019GenderMaleFemalePrimary Language Spoken at HomeCurrent/Previous Pre-School ProviderChild 33rd Child's Name First Last Date of Birth MM DD YYYY Child's Age as of 10/2019GenderMaleFemalePrimary Language Spoken at HomeCurrent/Previous Pre-School Provider Parent/Guardian InfoFather's Name First Last Father's Country of OriginMother's Name First Last Mother's Country of OriginWho does your child live with?*Mother and Father, Mother, Father, Grandparents, Guardian, or Other. (If "Guardian" or "Other," please specify)Mother and FatherMotherFatherGrandparentsGuardianOther personPlease specify Guardian or OtherStudent(s) Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone Numbers*Work Phone NumbersCell Phone Numbers Sibling InfoDoes the child(ren) currently have a Sibling(s) attending LEAP Academy University Charter School and/or the Rutgers Early Childhood Program?* Yes. Attending LEAP Academy Yes. Attending Rutgers Early Childhood Program No Name(s)Grade(s)Age(s)Name(s)Grade(s)Age(s)Do you currently have any children ages 2 years or younger that are eligible to enroll in the Early Learning Research Academy Program for Infants and Toddlers?*YesNoName(s)Grade(s)Age(s)Confirmation InformationYour Email address* Enter Email Confirm Email CAPTCHA
