Application
You can also find this application and other required documents on our
website: berry.edu/srelc
DATES CONTACTED
________________________
Date of Application____________________________ Date Application received by SRELC_____________________________
Child’s Name _________________________________________________________________________________________________________
Last
First
Middle
Name Called_________________________ Sex: _______Boy ______Girl
Email _________________________________________
Date of Birth__________________________________________ Home Telephone____________________________________________
Home Address________________________________________________________________________________________________________
Street
City
State
Zip
Father’s Name_______________________________________________________ Occupation____________________________________
Place of Employment_______________________________________________ Business Telephone__________________________
Mother’s Name______________________________________________________ Occupation____________________________________
Place of Employment_______________________________________________ Business Telephone__________________________
Is child living with both parents? ________Yes
________No
If not, please state person with whom the child lives and relationship to the child. ___________________________
_________________________________________________________________________________________________________________________
Name other schools or day cares child has attended and dates of enrollment. _________________________________
_________________________________________________________________________________________________________________________
The South Rome Early Learning Center admits children of any race, creed, sex, national and ethnic origin or
qualified handicap to all the rights, privileges, programs, and activities generally accorded or made
available to children at the South Rome Early Learning Center. The Center does not discriminate on the basis
of race, creed, color, sex, age, national and ethnic origin or qualified handicap in administration of its
education policies and admissions policies.
Please complete each item. Return the application to:
Director
South Rome Early Learning Center
Anna K. Davie
24 E Main St SW
Rome, GA 30161
A partnership of The South Rome Redevelopment Corporation, Rome City Schools, and Berry College
We will assist families with applications to the Childcare and Parent Services
(CAPS) program for subsidized childcare through the Division of Family and
children Services (DFCS).
Scholarships may be available and will be given based on family size and
income. We will work with individual families to determine the amount they
are able to pay each week.
For more information contact:
706-232-4913 (x2959) or [email protected]