CDC Application for Enrollment

Child's Name (required)

Class - Please specify "3 year old class" or "4 year old class"(required)

Child's Birthday (required) (ex. Jan 01 1884)

Race/Ethnic Origin

Gender

Exceptionality or Special need(s)

Primary Contact Email Address (required)

Home Address

Home Phone

Father's Name

Place of Employment

Phone

Mother's Name

Place of Employment

Phone

Are you an NSU employee?
YesNo

If you answered yes, please specify

Sibling Information