Application for Admission
Siemens CDC, an early childhood community (formerly Mentor Graphics CDC)
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Email *
Child's Name ("Baby" and 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
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DD
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YYYY
First Parent/Guardian's Name *
Email *
Primary Phone Number
Employer *
Required
Second Parent/Guardian's Name (please indicate none if there is only one legal parent/ guardian) *
Email *
Primary Phone Number
Employer
Preferred Mailing Address for Enrollment materials (including city and zip code) *
Does the child have a Grandparent who is a Siemens employee? *
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.