FRC Child Development Center Application

Please complete this form in full then click on the "submit" button at the bottom.

Date Date / MM / DD YYYY
Name of Parent or Guardian Name of Parent or Guardian First Last
Number of family members in the home
Mailing Address Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Email
Child's Name Child's Name First Last
Child's Date of Birth
(MM/DD/YYYY)
Child's Name Child's Name First Last
Child's Date of Birth
(MM/DD/YYYY)
What is the primary language in your household?
What is your Family Gross Monthly Income?
Need/eligibility for admission (check all that apply)

Need/eligibility for admission (check all that apply) CPS Referral Homeless Incapacitated Income Eligible Over Income PRS Payment Voucher Seeking Employment Socialization Student
The Child Development Center is open for Pre-School from 7:45 a.m. - 5:00 p.m. and Toddlers from 8:15 a.m. - 2:45 p.m. Please list your desired enrollment schedule, staying within the appropriate timeframe.

Please note that students are required to submit their current class schedule to the CDC.
Monday
Tuesday
Wednesday
Thursday
Friday