CDCB Enrollment Application
For: Infants not born yet
Child's Name (If you have not chosen a name, you use "Baby" as the first name.
*
First Name
Last Name
Due Date (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
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
Are you aware at this point of any anticipated special needs your baby will have?
*
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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