Enrollment Form

CDCB Enrollment Application
Child's Name

First NameLast Name
Date of Birth (MM/DD/YY)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Email
example@example.com
Child's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Ethnicity: (This information is only used for grant purposes)
Child's Gender
Family Information
Guardian 1 Name:
Phone Number:
Email:
Please indicate if you work for:
Guardian 2 Name:
Phone Number:
Email:
Please indicate if you work for:
Was your child premature?
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:
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:
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

USDDescription

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

CDCB Enrollment Application

Family Information

Please note:

ACCURACY OF INFORMATION

Enrollment Fee: $75*

Enrollment Fee: $75