28 Lyman Road
Northampton. Massachusetts 01063
T (413) 585-3290 F (413) 585-3292
www.smith.edu/forthill
cece@smith.edu
APPLICATION
FOR ADMISSION
I hereby apply for the admission of my  son  daughter
to the Smith College Center for Early Childhood Education
for the academic year 2016-2017 _________ and Summer 2016________.
APPLICANT INFORMATION
_______________________________________________________________________________
APPLICANT’S FULL NAME
______________________________________________________________________________________________
HOME ADDRESS
______________________________________________________________________________________________
TELEPHONE
BIRTH DATE/DUE DATE
FAMILY INFORMATION
_______________________________________
__________________________________
PARENT NAME
PARENT NAME
_________________________________________________
HOME ADDRESS
___________________________________________
HOME ADDRESS
_________________________________________________
___________________________________________
_________________________________________________
HOME TELEPHONE
___________________________________________
HOME TELEPHONE
_________________________________________________
OCCUPATION
___________________________________________
OCCUPATION
_________________________________________________
EMPLOYER
___________________________________________
EMPLOYER
_________________________________________________
BUSINESS ADDRESS
___________________________________________
BUSINESS ADDRESS
_________________________________________________
BUSINESS TELEPHONE
___________________________________________
BUSINESS TELEPHONE
_________________________________________________
E-MAIL ADDRESS
___________________________________________
E-MAIL ADDRESS
__________________________________________________________________________________________________________
NAMES AND BIRTH DATES OF SIBLINGS
ADDITIONAL INFORMATION
How did you learn about the Smith College Center for Early Childhood Education?
___________________________________________________________________________________________
What are your reasons for applying to the Center for Early Childhood Education?
_____________________________________________________________________
Does your child have any special strengths or needs that we should know about? Please describe briefly.
______________________________________________________________________
SCHEDULING OPTIONS:
INFANT PROGRAM (infants may enroll at two months; infant tuition applies to children younger than
15 months as of September 1st)
5 days
4 days
3 days
8:00 a.m. to 2:45 p.m.________
8:00 a.m. to 2:45 p.m.________
8:00 a.m. to 2:45 p.m.________
8:00 a.m. to 4:45 p.m._______
8:00 a.m. to 4:45 p.m._______
8:00 a.m. to 4:45 p.m._______
TODDLER PROGRAM (15 months-32 months of age as of September 1st)
5 days
4 days
3 days
8:00 a.m. to 2:45 p.m._________
8:00 a.m. to 2:45 p.m._________
8:00 a.m. to 2:45 p.m._________
8:00 a.m. to 4:45 p.m._______
8:00 a.m. to 4:45 p.m._______
8:00 a.m. to 4:45 p.m._______
Three- or four-day schedules will be accommodated on a space-available basis. If requesting a three- or
four-day schedule, please list the specific days you
prefer_______________________________________________
PRESCHOOL (2.9 years-4.11 years of age as of September 1st)
5 days
8:00 a.m. to 12:45 p.m _______ 8:00 a.m. to 2:45 p.m._______ 8:00 a.m. to 4:45 p.m. ______
RACE/ETHNIC CATEGORY (OPTIONAL):
 American Indian or Alaskan Native
 Asian or Pacific Islander  Hispanic
 Black, not of Hispanic Origin  White, not of Hispanic Origin  Other (specify) ____________
NOTICE OF NONDISCRIMINATION: Smith College is committed to maintaining a diverse community in an
atmosphere of mutual respect and appreciation of differences. Smith College does not discriminate in its educational
and employment policies on the basis of religion, race, color, creed, national/ethnic origin, sex, sexual orientation, age,
or with regard to the bases outlined in the Veterans Readjustment Act and Americans with Disabilities Act. The Smith
College Center for Early Childhood Education does not discriminate in providing services to children and their
families on the basis of race, religion, cultural heritage, political beliefs, national origin, marital status, sexual
orientation or disability. The following office has been designated to handle inquiries regarding the nondiscrimination
policies: Office of Institutional Diversity, College Hall #31, (413) 585-2141.
______________________________________________________________________
SIGNATURE OF PARENT OR GUARDIAN
APPLICATION FEE
A $30 non-refundable filing fee is required when application is filed.
Please make check payable to Smith College.
DATE