Child Development Center - Application
Complete a separate application for each child.
Enrollment Information
I am applying for my child to begin enrollment (check one):
Fall
Spring
Summer
Year
Days
Monday - Friday
Monday, Wednesday, Friday
Tuesday and Thursday
Hours
7:30 a.m. - 5:15 p.m.
Partial days (5 hours or less)
Has your child been in care previously:
Yes
No
If yes, care was
Family Home Daycare
Center Based
Other:
List if other
I am:
Full-Time Parkland Student
Part-Time Parkland Student
Parkland Employee
None of the above (community)
If you are a student, what is your
Projected Graduation Date:
Student ID:
Child Information
Name (First, Middle, Last):
Date of Birth (Month/Day/Year):
Gender:
Male
Female
Native Country / Ethnicity:
Street Address:
City:
State:
Zip:
Home Phone:
This child's parents are:
Single
Married
Separated
Divorced
Widowed
Annual Household Income Range (pick one):
0 - 34,999
35,000 - 59,999
60,000 +
Who has legal custody of this child? (check only one of the following options)
Both Parents
Mother
Father
Other
Relationship to Child:
Please list any suspected or diagnosed physical or mental conditions/limitations:
Does your child receive services from any other agency?:
Yes
No
If yes, please list:
Child's Mother / Co-Parent
Name:
Parkland ID (if student):
Address:
E-Mail:
Native Country / Ethnicity:
Place of Employment:
Work Phone:
Child's Father / Co-Parent
Name:
Parkland ID (if student):
Address:
E-Mail:
Native Country / Ethnicity:
Place of Employment:
Work Phone: