Child Development Research Center

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Parents or Guardian Name(s):

Child Information

*Name of Child:

*DOB (or due date):

*Gender

Female

Male

Name(s) of siblings (currently enrolled or in applicant pool):

Leave blank if not applicable

*Address:

City:

State

Zip:

Parent/Guardian Information

*Parent or Guardian Name:

Work or Home Phone:

*Cell Phone:

*E-mail:

Parent or Guardian Name:

Work or Home Phone:

Cell Phone:

E-mail:

*Enrollment Preference:

Full Time

MWF

TTh

Flexible/call for any

Family Demographic Information

*Language(s) spoken in the home:

*Special Needs:

Yes

If yes, please describe:

Family Structure: if other, please describe:

*Annual Family Income:

Below $25,000

$25,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000-$124,999

$125,000-$149,999

$150,000-$174,999

Over $175,000

*Financial Support

Not Applicable

Currently receiving CCS funding

Have applied for CCS funding

Will apply for tuition assistance through CDRC

A limited number of financial support opportunities are available.

PARENTS, please note: Children are NOT enrolled on a first-come, first-served basis. Selection of children is based on a comprehensive approach for the purpose of providing a high-quality teacher training and research program. By signing this form I am acknowledging that I have received and understand the application policies and procedures. I understand that my $50 application fee is due each year of application, does not imply eventual enrollment, and is non-refundable. Traditionally, there is a high ratio of children applying to the number of spaces available. Complete policies may be requested from the CDRC office and are available on the CDRC website: www.cdrc.ttu.edu.

I understand the disclosure above:

Yes

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Child Development Research Center

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