CDCB Enrollment Application
Child's Name
*
First Name
Last Name
Date of Birth (MM/DD/YY)
*
Phone Number
*
Please enter a valid phone number.
Your Email
*
example@example.com
Child's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Ethnicity: (This information is only used for grant purposes)
Child's Gender
Male
Female
Unknown
Family Information
Guardian 1 Name:
*
Phone Number:
*
Email:
*
Please indicate if you work for:
*
University of Kentucky Healthcare (UKHC)
University of Kentucky (UK)
Neither
Guardian 2 Name:
Phone Number:
Email:
Please indicate if you work for:
University of Kentucky Healthcare (UKHC)
University of Kentucky (UK)
Neither
Was your child premature?
*
yes
no
If yes, how premature?
Does your child have any health needs of which we need to be aware?
*
Has your Child ever been evaluated by an occupational therapist, physical therapist, speech therapist, psychologist, or any other developmental specialist? Please select all that apply:
*
OT
PT
Speech
Psychologist
Other Developmental Specialist
No
Please list all diagnoses your child has received. Mark N/A if there are none.
*
If you answered yes to any of the above, please list any explanations that would help us understand your child:
Please note:
We must request and and all diagnoses your child has received. Discovery of a known medical condition or psychological diagnosis after placement could cause disruption in the education of the children currently enrolled at CDCB, and, the education of your child as well, and could result in dismissal from the program.
I attest that all medical information has been disclosed to the best of my knowledge:
*
Agree
Disagree
ACCURACY OF INFORMATION
You hereby certify that all information provided to us by you is true and accurate in all respects.
Specify your relationship to the child:
*
Enrollment Fee: $75
*
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