Application Form
Please complete the form below and click submit.
Parent/Guardian Information
First Name
*
Last Name
*
Relationship
*
- Select One -
Mother
Father
Grandmother
Grandfather
Guardian
Joint Custody
Other
Address
*
Email
*
Phone
*
Child Information
First Name
*
Last Name
*
Date of Birth
*
Req. Start Date
*
Location
Cedar Hills Baptist Church
12716 N. Allen Road
Dunlap, IL
61525
309-361-8467
Secure Payment
Application Form Fee
: Select a location above
Name On Card
Credit Card
Submit
Application Form Successful
Your application has been received.