Rosemount Center Application

Page 1 of 8

Rosemount Center Application

  1. Please complete all 7 sections of the application to the best of your ability.
    If you are currently pregnant, please indicate the last name of the child and the due date. Note: When the child is born please call the enrollment department at Rosemount Center to update the information.

    Enrollment Options

    Early Head Start (EHS):

    Financial assistance for families who qualify, center-based and home-based program

    DC Department of Human Services assistance (DHS):

    Financial assistance for families who qualify, tuition center-based program

    Tuition:

    Center-based program

    Note: EHS/OSSE applicant must be a DC resident in order to qualify for the program.

  2. Application Date*
    Invalid Input
  3. Program Options*

    Invalid Input
  4. Age Group*

    Invalid Input
  5. Payment Options (check one)*
    Invalid Input

  1. Applicant

    (Child Applying for Services)
  2. First Name*
    Invalid Input
  3. Middle Name
    Invalid Input
  4. Last Name*
    Invalid Input
  5. Suffix
    Invalid Input
  6. Nickname
    Invalid Input
  7. Birthday*
    ||Invalid Input
  8. Gender*

    Invalid Input
  9. Race*
    Invalid Input
  10. Other Race
    Invalid Input
  11. Nationality (Country of Birth)*
    Invalid Input
  12. English Proficiency*
    Invalid Input
  13. Other Language
    Invalid Input
  14. Other Language Proficiency
    Invalid Input

  1. Primary Adult

    (Lives with child)
  2. First Name*
    Invalid Input
  3. Middle Name
    Invalid Input
  4. Last Name*
    Invalid Input
  5. Suffix
    Invalid Input
  6. Nickname
    Invalid Input
  7. Birthday
    / / Invalid Input
  8. Gender*

    Invalid Input
  9. Race*
    Invalid Input
  10. Race*
    Invalid Input
  11. Nationality (Country of Birth)*
    Invalid Input
  12. English Proficiency*
    Invalid Input
  13. Other Language
    Invalid Input
  14. Other Language Proficiency
    Invalid Input
  15. Highest Grade Completed*
    Invalid Input
  16. Employment Status*
    Invalid Input
  17. Child's Relationship*
    Invalid Input
  18. Custody*

    Invalid Input
  19. Check all that apply*


    Invalid Input
  20. If teen parent, subsidized?

    Invalid Input

  1. Contact Information

    for Primary Adult lives with Child
  2. Living Address*
    Invalid Input
  3. City*
    Invalid Input
  4. State*
    Invalid Input
  5. Zip*
    Invalid Input
  6. Ward #
    Invalid Input
  7. Home Phone*
    Invalid Input
  8. Work Phone
    Invalid Input
  9. Cell Phone
    Invalid Input
  10. E-mail Address*
    Invalid Input

  1. Secondary Adult

    (Lives with child)
  2. Is there a secondary Adult that lives with the child that you would like listed on the application.

    Invalid Input
  3. First Name
    Invalid Input
  4. Middle Name
    Invalid Input
  5. Last Name
    Invalid Input
  6. Suffix
    Invalid Input
  7. Nickname
    Invalid Input
  8. Birthday
    / / Invalid Input
  9. Gender

    Invalid Input
  10. Race
    Invalid Input
  11. Race
    Invalid Input
  12. Nationality (Country of Birth)
    Invalid Input
  13. English Proficiency
    Invalid Input
  14. Other Language
    Invalid Input
  15. Other Language Proficiency
    Invalid Input
  16. Highest Grade Completed
    Invalid Input
  17. Employment Status
    Invalid Input
  18. Child's Relationship
    Invalid Input
  19. Custody

    Invalid Input
  20. Check all that apply


    Invalid Input
  21. If teen parent, subsidized?

    Invalid Input

  22. Contact Information

    for Secondary Adult
  23. Cell Phone
    Invalid Input
  24. Home Phone
    Invalid Input
  25. Work Phone
    Invalid Input
  26. E-mail Address
    Invalid Input

  1. Family/Household Information

  2. Child lives with*


    Invalid Input
  3. Children in family living with child
  4. Total children ages birth to 18
    Invalid Input
  5. Number of children ages Birth to 3
    Invalid Input
  6. Number of children ages 4 to 5
    Invalid Input

  1. Family Members

    (Please do not include adults and child listed previously)
  2. Number of family members living with child
    Invalid Input

  3. Family Member (1)

  4. Name
    Invalid Input
  5. Relationship to Child
    Invalid Input
  6. Date of Birth (month/day/year)
    / / Invalid Input
  7. School/Current Grade or Occupation
    Invalid Input
  8. Live with family?

    Invalid Input
  9. Provides financial support?

    Invalid Input

  10. Family Member (2)

  11. Name
    Invalid Input
  12. Relationship to Child
    Invalid Input
  13. Date of Birth (month/day/year)
    / / Invalid Input
  14. School/Current Grade or Occupation
    Invalid Input
  15. Live with family?

    Invalid Input
  16. Provides financial support?

    Invalid Input

  17. Family Member (3)

  18. Name
    Invalid Input
  19. Relationship to Child
    Invalid Input
  20. Date of Birth (month/day/year)
    / / Invalid Input
  21. School/Current Grade or Occupation
    Invalid Input
  22. Live with family?

    Invalid Input
  23. Provides financial support?

    Invalid Input

  24. Family Member (4)

  25. Name
    Invalid Input
  26. Relationship to Child
    Invalid Input
  27. Date of Birth (month/day/year)
    / / Invalid Input
  28. School/Current Grade or Occupation
    Invalid Input
  29. Live with family?

    Invalid Input
  30. Provides financial support?

    Invalid Input

  31. Family Member (5)

  32. Name
    Invalid Input
  33. Relationship to Child
    Invalid Input
  34. Date of Birth (month/day/year)
    / / Invalid Input
  35. School/Current Grade or Occupation
    Invalid Input
  36. Live with family?

    Invalid Input
  37. Provides financial support?

    Invalid Input

  1. Government Funding Information

    To be considered for Early Head Start and/or DHS (District of Columbia), please indicate which of the following services your family receives. (Check all that apply)












  2. Invalid Input

  3. Development Information

    Do you have any concerns about your child’s development, physical, or emotional progress? Has your child ever been assessed for special need? Does your child have an IEP or IFSP? If yes, please explain.
  4. Invalid Input
  5. *
    Invalid Input
  6. Invalid Input

Need More Info?

For tuition questions or clarification, please contact Campbell Frank at (202)265-9885 ext.115.

For Early Head Start or OSSE questions, please contact Remberto Vargas at (202)265-9885 ext. 101.

View the Admissions Applications: