Enrollment Form

I am requesting enrollment for my child as: *

Developing TypicallyDevelopmental DelaySuspected Developmental DelayTransitional Kindergarten (Must turn 5 June 1 - December 1)

Child's Name *

Date of Birth *

Phone Number *

Child's Address *

Child's Ethnicity

Child's Gender *

MaleFemale

Child is in the custody of: *

Child resides with: *

FAMILY INFORMATION

Guardian 1: *

Phone : *

Email : *

Employer's Name : *

Employer's Phone : *

Guardian 2:

Phone :

Email :

Employer's Name:

Employer's Phone :

MEDICAL HISTORY

Was your child's birth normal? *

YesNo

If not, why?

Was your child premature? *

YesNo

If yes, how premature?

Has your child been healthy since birth? *

YesNo

Has your child had significant illnesses? *

YesNo

If yes, explain?

Has your child ever been hospitalized? *

YesNo

If yes, explain?

List any examinations your child has recently had:

List the specialist, date, results, and diagnosis of each

List any other health concerns you would like your child's teacher to know.

List any other diagnosis (medical or psychological) that your child has received. *

List any developmental screenings that your child has participated in. *

Please note
We must request any and all diagnoses your child has received. Discovery of a known medial or psychological diagnosis after placement could cause disruption in the education of the children currently enrolled at CDCB, and, the education of your child as well, and could result in dismissal from the program.

I attest that all medical information has been disclosed to the best of my knowledge: *

AgreeDisagree

ACCURACY OF INFORMATION
You hereby certify that all information provided to us by you is true and accurate in all respects.

Specify your relationship to the child *