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Academy Info

+1 302-659-0750

Early Care Education Program Application

Contact Rainbow Xpress Learning Academy

Address

310 N. Main Street,
Building A,
Smyrna, DE 19977

Phone

302-659-0750

Operating Hours

Monday to Friday
6:30 am to 5:30 pm

Payment methods

Cash App $rxlearningacademy
Zelle rxlearningacademy@outlook.com
Brightwheel

Please enable JavaScript in your browser to complete this form.

– Step 1 of 3

Child *

First

Middle

Last

Sex *

DOB *

Child's Address *

Address Line 1

City

State

Zip Code

Child lives with (check all that apply) *

Mother
Father
Grandparents
Relatives
Friends
Other

Select all that apply

Housing Status *

Own
Rent
Living with someone else
Other

Race of child *

American Indian
Alaska Nativ
Asian
Black/African Amer.
Native Hawaiian.
Pacific Islander.
White
Biracial/Multi-Racial
Unspecified
Other

Other *

Ethnicity of child *

Hispanic/Latino
Non-Hispanic/Non-Latino

Language Information

Primary Language *

Secondary Language (if applicable)

Level of English Fluency *

Fluent
Proficient
Moderate
Poor
None

Does your child have any siblings enrolled in our program? *

Yes
No

Does this child have any disabilities or medical conditions (diagnosed by a doctor or specialist services?) *

Yes
No

If yes, specify

Does your child have an established IFSP/IEP Plan? *

Yes
No

Did your child Previously attend Daycare/School? *

Yes
No

If yes, where?

Do you have any concerns about your child in any of the following areas (check all that apply) *

Hearing
Asthma
Vision
Other medical concerns
Underweight
Physical Development
Overweight
Behavioral Problems
Speech or Language
Emotional Problems
Dental Issues
Other Developmental Concerns
Allergies
None

If you checked any category, please describe your concerns below:

Primary Adult *

Parent
Guardian

Do You Have Legal Custody *

Yes
No

Relationship to child

Natural/Adopted/Stepparent
Grandparent
Aunt/Uncle
Foster parent
Other

Other

Adult's English Proficiency

Fluent
Proficient
Moderate
Poor
None

If English is not adult’s primary language, please specify the primary language

Parent/Guardian

First

Middle

Last

DOB *

Parent's Address

Address Line 1

City

State

Zip Code

Primary Phone *

Secondary Phone

Head of Household

Yes
No

Teen Parent

Yes
No

Employment Status *

Full time
Part time
Unemployed
Seasonally Unemployed
Enrolled in School and/or Training Program
Disabled
Retired

Adult's Education Level *

Less than High School
High School Diploma
GED
Some College, no degree
Enrolled in School and/or Training Program
Associate’s degree
Bachelor’s degree
Masters or Doctorate Degree

Occupation *

Email Address *

Has diagnosed chronic health issues or disability: *

Yes
No

Has diagnosed mental illness: *

Yes
No

If yes, please specify below and provide documentation with application:

Secondary Adult *

Parent
Guardian

Do You Have Legal Custody *

Yes
No

Relationship to Child *

Natural/Adopted/Stepparent
Grandparent
Aunt/Uncle
Foster parent
Other

Adults English Proficiency *

Fluent
Proficient
Moderate
Poor
None

If English is not adult’s primary language, please specify the Primary language

Primary Phone *

Secondary Phone

Head of Household *

Yes
No

Teen Parent *

Yes
No

Employment Status *

Full time
Part time
Unemployed
Seasonally Employed
Enrolled in School and/or Training Program
Disabled
Retired

Adult’s Education Level *

Less than High School
High School Diploma
GED
Some College, no degree
Associate’s degree
Bachelor’s degree
Masters or Doctorate Degree

Occupation *

Email Address *

Has diagnosed chronic health issues or disability *

Yes
No

Has diagnosed mental illness *

Yes
No

If yes, please specify below and provide documentation with application

Total Number of people in household *

Gross Income *

Is your family receiving any of the Following (Check all that apply): *

Child Care Subsidies
Foster Care or Adoption Subsidies
Mental Health Services
Supplemental Nutrition Assistance program (SNAP)
Temporary Assistance for Needy Families (TANF)
Medical Assistance
Public Housing
Energy Assistance
Health Services
Child Support or Alimony
Social Security Disability Insurance (SSDI)
Supplemental Nutrition for Women, infant
Supplemental Security Income (SSI)
Unemployment Insurance
None

Incarcerated Parent? *

Yes
No

Is your family currently dealing with any legal issues such as family court, divorce, probation/parole, custody, or restraining orders? *

Yes
No

Does child have regular provider (physician) *

Yes
No

Name of child’s physician *

Address of child’s physician *

Phone Number *

Last Physical *

Last Dental check-up *

Last Vision Screening *

Up-to-date immunizations *

Yes
No

Does this child have any allergies? *

First Name

Last name

Email Adress

Phone Number

Preferred Date of Visit

Preferred Time of Visit

Message

Zelle

Rainbow Xpress Learning Academy

Cashapp

Rainbow Xpress Learning Academy

Brightwheel

Rainbow Xpress Learning Academy

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310 N. Main Street,
Building A,
Smyrna, DE 19977

Phone: (+1) 302-659-0750

Email: Kindly Use Form

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