CDC Application

Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Child's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child Lives With *

Both Parents Together

Foster

Mom

Dad

Grandparent

Other

Home Phone

(###)

###

####

Best Way to Contact

Email

Mom Cell

Dad Cell

Home

Work

Days you would like your child to attend: *

Monday

Tuesday

Wednesday

Thursday

Friday

Full Week

Flexible Days

Mother's Name

First Name

Last Name

Mother's Cell

(###)

###

####

Mother's Work Phone

(###)

###

####

Father's Name

First Name

Last Name

Father's Cell Phone

(###)

###

####

Father's Work Phone

(###)

###

####