Infant Enrollment Request
Ages 6 weeks old to 1 year old
Child's First Name
*
Child's Last Name
*
Child's Date of Birth (or expected date)
*
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Parent/Guardian Phone Number
*
Parent/Guardian's Email Address
*
example@example.com
How Soon Do You Need Child Care?
*
Immediately
Within 1-2 Weeks
Within 3-4 Weeks
At a Later Date
If you selected "At a Later Date" select your anticipated start date:
-
Month
-
Day
Year
Date
Select Your Tuition Plan:
*
Private Pay
Child Care Certificate (Voucher)
Military Child Care in Your Neighborhood (MCCYN)
Child Care Aware of America
Important Notes About Your Child and/or Enrollment Request:
Submit
Should be Empty: