Registration Application
Email address *
Todays Date *
MM
/
DD
/
YYYY
Applying For *
Child's Full Name *
Your answer
Date Of Birth *
MM
/
DD
/
YYYY
Child's Gender *
Child's Age *
Your answer
Street Address *
Your answer
City *
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Zip *
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Parent/Guardian Name *
Your answer
Contact Phone Number *
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Check One *
Required
CSUDH Student ID Number:
Your answer
Second Parent / Guardian Name
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Enrollment Preference- F = 6.5 to 10 hours FS = 4 to 6 hours between the hours for 7:30am and 2:00pm PTA = 3.75 hours between 8:45am to 12:00pm *
Required
Would you like to apply for subsidized funding?
If you would like to apply for subsidized funding please provide number of persons in the family
If you would like to apply for subsidized funding please provide estimated household monthly income
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Please Enter Your Name Here Confirming This Information *
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