Child Development Center/Lab School

Preliminary Application

Please fill out all of the following information.

Parent/Guardian Information

Name:

Address:

City:

Zip:

Phone:

Email:

Child and Family Information

Number of Members in the Family:

Child #1

Child Name:

Birthdate:

Day & Time of Care Needed:

[+] Add Another Child

Parent/Guardian Employment

Primary Parent/Guardian

Employer:

Address:

Phone:

Days & Hours Worked:

Secondary Parent/Guardian

Employer:

Address:

Phone:

Days & Hours Worked:

Parent/Guardian Presently in School

Primary Parent/Guardian

School Name:

Current Enrollment Units:

Vocational Goal:

Days & Hours of Classes:

Secondary Parent/Guardian

School Name:

Current Enrollment Units:

Vocational Goal:

Days & Hours of Classes:

Parent/Guardian Gross Income

TANF:

SSI/SSP:

Wages:

Pension:

Worker's Comp:

Alimony:

Child Support Received:

Child Support Paid:

Income:

Other:

Total Gross Income:

Verification of the above will be needed at the time of enrollment.

Cerro Coso Student Email Please leave this field empty.

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