If you have any questions or wish to schedule a tour before applying, please contact Director Lisa Kampwirth at director@totalchild.org or 847.864.7100.

Please note our application includes a $50 non-refundable application fee.

Please complete one application per child.

Child’s Name *

First

Last

Date of Birth

Sex

Program for Which You Are ApplyingFull Day 2’s (Child must be 2 by September 1)Full Day 3’s (Child must be 3 by September 30)Full Day 4’s (Child must be 4 by September 30)Kindergarten (Child must be 5 by October 30)

Select one.

Parent/Guardian Information

Parent #1 Name *

First

Last

Parent #1 Email *

Parent #1 Cell Phone *

Parent #1 Home Address

Address Line 1

Address Line 2

City

IllinoisAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Parent #2 Name

First

Last

Or write n/a if not applicable

Parent #2 Email

Parent #2 Cell Phone

Parent #2 Home Address

Address Line 1

Address Line 2

City

IllinoisAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Complete if other than address #1.

Other Information about Child or Family

How Did You Hear About Us? *

Application Fee

$50, non-refundable

Please choose one: *

• I will mail my check payable to TOTAL CHILD for $50
• Charge my credit card $50

Application Fee

Price: $50.00

Credit Card Information *

Card

Name on Card

Signature *

Clear Signature

My signature affirms the information I've entered on this form is true to my knowledge.

Submit