Child Development Center Intake Form

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Thank you for your interest in Chinese Community Center's Child Development Center! We are dedicated to serve families with children from 18 months to 5 years old. We have the most openings in August right before school starts.

Please fill in your information below and our staff will contact you regarding our program enrollment shortly.

Guardian's First Name *

Guardian's Last Name *

Phone Number *

Format XXX-XXX-XXXX

E-mail

Child's First Name *

Child's Last Name *

Child's Date of Birth *

YYYY

Requested Childcare Start Date *

YYYY

Notes (dietary restrictions, special needs, financial needs, etc.)

Submit

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