Enrollment Application – Early Childhood Development Center

Application for Enrollment

Application Date(Required)

Desired Enrollment Date(Required)

Child's Name(Required)

First Last

Child's Date of Birth(Required)

Full or Part Time(Required)

Full Time

Part Time

Ethnicity(Required)

Caucasian

African American

Hispanic/Latino

Asian

Other

Gender(Required)

Female

Male

Home Language(s)(Required)

Special Needs or Learning Needs(Required)

Siblings Enrolled in the Program(Required)

Parents' #1 Name(Required)

First Last

Parents' #2 Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent #1 Phone(Required)

Parent #1 Email(Required)

Parent #2 Phone(Required)

Parent #2 Email(Required)

Cofc Affiliation (List One Or More)(Required)

Ex: Faculty/Staff, CofC Student, CofC Alumnus, Community