Child's Name *
Child's Name
Child's Birthdate *
Child's Birthdate
Parent
Parent/Guardian Address
Parent/Guardian Address
Business Phone
Business Phone
Parent/Guardian
Parent/Guardian Address
Parent/Guardian Address
Please check all that apply
Desired Days of Attendance
*CCYC Opens at 7:00am
*CCYC Closes at 5:30pm
Desired Start Date
Desired Start Date
Placement Preference*
*Child’s age as of August 1st