Preschool Enrollment Form

Thank you for your interest in enrolling your preschooler with Child Development Centers, Inc.

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

Child's Name

First Name *

Last Name *

Birthday

Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Primary Contact Name

First Name *

Last Name *

Relationship to Child (Required)

Relationship to Child

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Email (Required)

Phone (Required)

Phone

Did your child attend an Early Head Start Program?

Did your child attend another Head Start Program? (If yes, please site below)

If you answered yes to either of the above question, please site:

Is your child involved with Children, Youth, & Families?

Yes (If yes, please provide the caseworker's name below)
No

If your child is involved with Children, Youth, & Families, please list their caseworker.

Is your child a Foster Child?

Do you have a Custody Agreement?

Do you have educational rights?

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Total Yearly Income (Required)

Gross Annual Income

SSI

Is your family receiving Supplemental Security Income (SSI)?

SNAP (Food Stamps)

Is your family receiving SNAP benefits (Food Stamps)?

TANF

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

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Number in Household (Required)

Number of People Living in the Household

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Do you have any special needs or concerns for your family such as (check all that apply)

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Is your family (check all that apply)

Homeless
Living with Family
In a Shelter
In a Multi-Family Arrangement with Documentation
Working with Children, Youth, & Families
None of the Above

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Does your child have an educational, medical or mental diagnosis? (Check all that apply)

Educational Diagnosis/Developmental Delays (Ex: IU, IEP)
Mental Health Diagnosis (Ex: Autism, ADHD, ODD)
Physical Disability
Medical Diagnosis (Ex: Allergies, Milk Intolerance)
None of the Above

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Do you have an educational or behavioral concern for your child or yourself? (Check all that apply)

Speech or Fine/Gross Motor, Etc.
Behavioral
Post-Partum Depression
None of the Above

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CDC requires all young learners to receive their Primary Immunizations: https://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf.
This does not include the COVID-19 vaccine.

Has your child received their recommended immunizations?

Yes
Not yet
My child will not receive their recommended immunizations

How did you hear about us? (If referred, please list the name of the person that referred you) (Required)

How did you hear about us?