CCC Child Development Center Enrollment Interest Form

1. Contact Information

Contact Information Parent First Name:
Parent Last Name:
Parent Address:
Parent Address 2:
Parent City/Town:
Parent State:
Parent ZIP/Postal Code:

2. Daytime Phone #

Daytime Phone #

3. Evening Phone #

Evening Phone #

4. Email Address:

Email Address:

5. Best time to reach you:

Best time to reach you:

6. Best way to reach you:

Best way to reach you:

7. Child's Name:

Child's Name:

8. Age:

Age:

9. Child's Date of Birth:

Child's Date of Birth:

10. When do you need care?

	Month	Year
Select Month and Year	When do you need care? Select Month and Year Month	Year

11. I am interested in enrolling my child at the Child Development Lab Center located at the college(s) marked below (check all that apply):

I am interested in enrolling my child at the Child Development Lab Center located at the college(s) marked below (check all that apply): Daley College

Kennedy-King College

Malcolm X College

Olive-Harvey College

Truman College

12. How did you hear about us?

How did you hear about us?

Other (please specify)