Good Shepherd Early Learning Center Application

1297 Amherst Place, Saint Louis, Missouri 63112
Enter all information in English
You MUST Submit before leaving this form or ALL entries will be lost.

Child

Enter the child's full name (example: use Joseph not Joe)
Gender *
 +

Program

Select the school year you are applying for
If you are applying for your child to attend our preschool, check the preschool days you want your child to attend.
Preschool days
If you are applying for your child to attend our before or after school program, check the days below and enter the name of the child's school.
Before school care days
After school care days

Parent or legal guardian signature

Enter telephone number as 10 digits with no other characters

USDA Nondiscrimination Statement

For all other FNS nutrition assistance programs, State or local agencies, and their subrecipients, must post the following Nondiscrimination Statement:

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participation in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complain, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
(1) Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW Washington, D.C. 20250-9410;
(2) Fax: (202) 690-7442; or
(3) Email: program.intake@usda.gov
 
This institution is an equal opportunity provider.