Application for Admission
Mentor Child Development Center
Email address *
Child's Name ("Baby" and your last name if unknown) *
Birth date or Due date *
MM
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DD
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YYYY
Child's Sex *
Enrollment Schedule Requested *
The CDC offers full days only. Full day schedules other than those listed may be available by special arrangement. Please indicate your preferred schedule of days under "Other"
Enrollment start date requested *
MM
/
DD
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YYYY
Parent/Guardian's Name *
Email *
Primary Phone Number
Employer *
Required
Parent/Guardian's Name
Email
Primary Phone Number
Employer
Preferred Mailing Address for Enrollment materials (including city and zip code) *
Is either parent/guardian considered an 'essential worker' (medical, public services, infrastructure, food distribution, etc.) currently working outside the home? *
Do you currently have concerns about your child's development or behavior? *
If yes, please describe.
Is your child currently receiving developmental services (Speech, OT, PT, etc.)? *
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Mentor Graphics Corporation.