EXIT

Community Enrollment Application

Please complete the below application to get placed on the wait-list for Hayes Child Development Center.

Please note, you will need to submit the following documents:

*Child's Immunizations

*Most Recent Well Child Exam

*Parent/Guardian Photo ID

*Most Recent Dental Exam (1 yr +)

Please submit them either in person or via email to angela.johnson@cptc.edu and CC rachael.butler@cptc.edu

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* 1. Child First and Last Name:

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* 2. Child Information:

Male

Female

Birthday

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* 3. Primary Parent Information

Parent Name

Place of Employment & Number

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 4. Secondary Parent Information (if applicable)

Parent Name

Place of Employment & Number

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 5. We are open 6:30am to 5:30pm and closed on Holidays. All children need to be dropped off by 9:30 to start their day. What hours of care do you need?

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* 6. Monthly child care costs will be paid by:

Self-Pay (Cash, debit, credit, MO)

Army Fee Assistance (CCAoA)

Tribal Assistance

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* 7. Is your child currently in care? If 'Yes' with who? (Select all that apply)

Yes

Never been in care

Only with Family/Friends/Neighbor

Child Care Center

Only with Parent

Other (please specify)

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* 8. What is the child's home language?

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* 9. Please select all that apply:

No Concerns

Allergies: Food/Milk

Respiratory (i.e. Asthma, uses nebulizer/inhaler)

Hearing Concerns

Vision Concerns

Speech Concerns

Behavior Concerns

Physical Concerns

Developmental Concerns

Other (please specify)

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* 10. My child is in the process for/or currently has: (select all that apply)

IEP

IFSP

SSI

Diagnosed Disability (i.e. sensory, autism, ADHD)

Other (please specify)

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* 11. Select any that apply:

Adopted

Past or Present Abuse/Neglect

Past or Present CPS

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* 1. Child First and Last Name:

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* 2. Child Information:

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* 3. Primary Parent Information

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* 4. Secondary Parent Information (if applicable)

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* 5. We are open 6:30am to 5:30pm and closed on Holidays. All children need to be dropped off by 9:30 to start their day. What hours of care do you need?

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* 6. Monthly child care costs will be paid by:

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* 7. Is your child currently in care? If 'Yes' with who? (Select all that apply)

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* 8. What is the child's home language?

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* 9. Please select all that apply:

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* 10. My child is in the process for/or currently has: (select all that apply)

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* 11. Select any that apply:

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* 12. Please share any information you would like us to know.