Date of Application:

Current E-mail Address:

Child's Name:

    Boy     Girl

Birth date:

Home Phone (with area code):

Address:

Parent's Name:

Home Phone (with area code):

Address (if different from above):

Employer:

Work Phone:

Parent's Name:

Home Phone (+ area code):

Address (if different from above):

Employer:

Work Phone:

I am requesting enrollment for my child at Child Development Laboratory by:

Please Indicate Program:

Young Preschool (2 and young 3 year old)
Multi-age Preschool

Has your child had previous group care experiences?     Yes            No

If yes, briefly describe:

Is there any information regarding your child that would be important for the Child Development Laboratory to know prior to enrollment?

What are your expectations for the program offered by the Child Development Laboratory?