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 *