NOTE: Please fill out one application for each child.

Jubilee staff will use the information you provide in order to help your child, and to ensure quality programs.  Your information will be kept private.

If you need technical assistance, please email Jessica Miller, Quality Assurance and Data Manager at jmiller@jubileecenter.org or call 214-887-1364 ext. 241. 

Child's Name *
Child's Name
Child's Date of Birth *
Child's Date of Birth
Child's School: Please select
Parent/Guardian #1 Phone *
Parent/Guardian #1 Phone
Parent/Guardian #1 Date of Birth
Parent/Guardian #1 Date of Birth
Parent/Guardian #2 Phone Number
Parent/Guardian #2 Phone Number
Parent/Guardian #2 Date of Birth
Parent/Guardian #2 Date of Birth
This person has permission to pick your child up or be called in the event of an emergency.
Authorized Individual #1 Phone 1 *
Authorized Individual #1 Phone 1
Phone 2
Phone 2
Authorized Individual #3 Phone
Authorized Individual #3 Phone
Student Lives With (Check all that apply)
If yes, please check all that apply *
Medications (Check all that apply)
Is your child allergic to anything? *
Has your child been diagnosed with a learning difference? (Check all that apply) *
If yes, which one (check all that apply)
For adults: would you be interested in the following:
By checking below I certify I am the parent/guardian of the child listed on the application. *