School Application Form

Delhi Campus Child Care Center Inc.

Application for Childcare Services
Mailing address: 454 Delhi Dr., SUNY Delhi Delhi, New York 13753

Physical location: 1104 Arbor Hill Rd Delhi, NY 13753

Office: (607) 746-4710 Fax:(607) 746-4709

Email: dc4@delhi.edu

Website: https://childcare.delhi.edu

Application fee of $10.00 must be received within one week of the application date.

Payments may be made by cash, check, or card.
Student Name

First NameLast Name
Date of Birth (or Due Date)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender

Other
Desired Enrollment Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Family Size
Requesting Care For
Type of Care Needed
Weekdays When Care is Needed
Please include time of care needed as well as any information about part time care. (Ex. M-F 8am-5pm, or T/TH 7am-Noon)
Enrollment Type
Parent/Guardian's Information
Parent/Guardian's Name - Primary

First NameLast Name
Occupation
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Parent/Guardian's Name - Secondary

First NameLast Name
Occupation
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
State Affiliation Information: This information is used to determine if your family is eligible for any of our additional tuition discounts.
Please indicate if you are a member of any of the following NYS Unions: CSEA, UUP, GSEU, DC-37, Council 82, NYSCOPBA, M/C, PBANYS
Tuition fees are based on a sliding fee scale, with proof of income upon enrollment. Please indicate your level of gross family income. Should you choose to not disclose your income you will be charged the highest tuition rate.
Payment Method (for application fee)
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature
Should be Empty:

Delhi Campus Child Care Center Inc.

Parent/Guardian's Information