Register Please fill out the form to the best of your ability. Step 1 of 5 20% Child's InformationChild's Full Name(Required) First Middle Last Name CalledAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Phone Number(Required)Primary Email Address(Required)Please enter the email most likely to be checked regarding this child. You will be able to enter additional email addresses later. Enter Email Confirm Email Gender(Required) Male Female Age as of 09/30/2025(Required)Language(s) Spoken in the Home(Required)Child Lives With:(Required) Mother Father Both Mother and Father Other If other, please specify:(Required)Person having legal custody: Family InformationMother's Name(Required) First Last Mother's Email(Required) Enter Email Confirm Email Mother's Occupation(Required)Mother's Business Phone(Required)Mother's Cell Phone(Required)Father's Name(Required) First Last Father's Email(Required) Enter Email Confirm Email Father's Occupation(Required)Father's Business Phone(Required)Father's Cell Phone(Required)Sibling Names and Ages(Required) Emergency Contactsother than parentsEmergency Contact 1 Name(Required) First Last Emergency Contact 1 Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact 1 Phone(Required)Relationship to Child(Required)Emergency Contact 2 Name(Required) First Last Emergency Contact 2 Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact 2 Phone(Required)Relationship to Child(Required)Physician Name(Required)Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Other InformationTo help us get to know your child better.What are your expectations for your child in this class?(Required)Please list any fears, habits, or family changes that may affect your child's behavior.(Required)Are there any medical or physical issues (including food allergies) so that we can help keep your child safe at school?(Required) Yes No If yes, please specifyHas your child been screened to receive special services?(Required)medical, educational, or therapeutic Yes No If yes, please specifyDoes your child have now, or previously had, an Individualized Education Plan (IEP)?(Required)If yes, please submit a summary of services and status. Yes No Does your family have an Individualized Family Service Plan (IFSP)?(Required) Yes No Has your child previously been enrolled in another preschool or day care?(Required) Yes No If yes, please list name and location:(Required)Are you a member of Huguenot Road Baptist Church?(Required) Yes No What is your Church Home?(Required) PoliciesWe do not discriminate on the basis of race, color, religion, national origin or sex of children seeking enrollment in the Child Develpment Center. It is our intention that all applicants are given equal opportunity, and that enrollment is based on available age-appropriate space. Please read our registration policies.Policy Agreement(Required)By checking this box and submitting this registration form, I agree that I have read and agree to these policies. I agree to the policies.CommentsThis field is for validation purposes and should be left unchanged. Δ
