Infant Toddler Enrollment Form

Thank you for your interest in enrolling your infant/toddler with Child Development Centers, Inc.
Please note, infant/toddler care is only available in Crawford and Venango counties at this time.

Please fill out the information below and an enrollment specialist will follow up with you as soon as possible.

Parent / Guardian Name

First Name

Last Name

Relationship to Child (Required)

Email (Required)

Phone (Required)

Address

Country

Address Line 1

City

State

Postal Code

County (Required)

Child's Name

First Name

Last Name

Birthday

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Number in Household (Required)

Number of People Living in the Household

Gross Annual Income (Required)

Gross Annual Income

Home

Do you rent or own your own home?

TANF

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?

SSI

Is your family receiving Supplemental Security Income (SSI)?

Infant / Toddler Enrollment