Welcome to the Xiente Early Learning Academy interest form.
Thank you for your interest in our Early Learning Academy program. This form helps us learn more about your child and your family so we can determine the next steps for enrollment.
Please complete all required sections with accurate information. You may be asked to provide your child’s name, date of birth, parent/guardian contact information, preferred language, household information, and any special needs or concerns we should know about.
Completing this form does not guarantee enrollment. A member of our team will review your submission and contact you with additional information, required documents, and next steps.
If you need help completing this form, please contact Xiente. We are here to support you.
Please complete this section with your family’s current address information.
First, let us know if your family is currently experiencing homelessness. This helps us better understand your family’s situation and provide the right support.
Enter your current living address. This is the address where the child and family are currently staying or living.
If your mailing address is the same as your living address, please select that option. If your mailing address is different, please enter the full mailing address where you can receive mail.
Please make sure the address, ZIP code, city, and state are correct before submitting.
Complete this section if there is another parent or guardian who should be listed for the child.
Please include their full name, relationship to the child, phone number, email address, and any other required information.
Are there other adults in the household?
Complete this section with information about your family and household.
Please answer all questions about parental status, relationship to the child, language spoken at home, household size, income, and benefits such as TANF, SSI, WIC, or SNAP.
This information helps us determine eligibility and better understand your family’s needs.
Child Care Subsidy / ELRC / CCIS
If your family currently receives, has applied for, or may be eligible for ELRC child care subsidy, also known as CCIS, please include this information in the notes section. This helps us understand your child care funding status and support you with the enrollment process.
IEP / IFSP Information
Please let us know if your child has an Individualized Education Program (IEP) or an Individualized Family Service Plan (IFSP). This helps our team better understand your child’s needs and plan for appropriate support during the enrollment process.
Do you want to apply now for another child in your family?
Are there other children in the family?
Thank you for completing the Xiente Early Learning Academy interest form.
By submitting this form, you confirm that the information provided is complete and accurate to the best of your knowledge.
Please remember that completing this form does not guarantee enrollment. A member of our team will review your submission and contact you to discuss the next steps, required documents, and intake appointment availability.
If your contact information changes after submitting this form, please contact Xiente as soon as possible so we can reach you.
We look forward to speaking with you and learning more about your child and family.