Childcare Enrollment – Edstar Analytics

Child Information

Child First Name(Required)

Child Middle Name

Child Last Name(Required)

Child Date of Birth(Required)

Child Gender

Primary Language

If Other Language, specify

Child Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Race/Ethnicity (optional, select one that best applies)

Parent/Guardian Information

Primary Parent/Guardian Full Name(Required)

Relationship to Child(Required)

If Other Relationship, specify

Parent/Guardian Email

Parent/Guardian Phone

Parent/Guardian Address (if different)

Street Address Address Line 2 City State ZIP Code

Preferred Contact Method

Phone

Email

Text Message

Secondary Parent/Guardian Full Name

Secondary Parent/Guardian Phone

Secondary Parent/Guardian Email

Illinois CCAP / Subsidy Intake

Is the child receiving Illinois Child Care Assistance Program (CCAP) benefits?(Required)

CCAP Case Number

Primary Parent/Guardian RIN (if known)

Child RIN (if known)

CCAP Eligibility Start Date

Monthly Family Co-Pay (USD)

Parent Activity Type

Employer/School Name

Work/School Schedule (e.g., Mon–Fri 8:30a–4:30p)

Consents & Acknowledgments

Health Treatment Authorization

I authorize emergency medical treatment for my child when I cannot be reached.

Photo/Media Consent

I consent for my child’s image to be used in program materials, newsletters, and social media.

Provider Use Only

Provider Name

Provider License/ID Number

Site/Room

Start Date (Provider)

Notes

Sample Childcare Enrollment Form

Key Benefits:

Complete the Enrollment Form Below

Child Information

Parent/Guardian Information

Illinois CCAP / Subsidy Intake

Enrollment Schedule & Program

Typical Weekly Attendance (up to 3 patterns)

Authorized Pickup Persons (up to 3) — ID required

Emergency Contacts (up to 3) — not living with child

Medical Information

Consents & Acknowledgments

Quick Process

Secure Storage

Instant Reports