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Adele and Dale Young Child Development Laboratory

Enrollment Application

Please fill out the information below. When this application is received, the child's name will be placed on the Child Development Laboratory Waiting Lists as indicated. Each wait list is separated by age groups. Be sure to check the boxes of the corresponding program you would like your child on the wait list for. We will accept 3/4 of each school group for each lab on the basis of the application date. We will accept the remaining 1/4 of each group based on other specific criteria (referrals from medical professionals, etc). Please keep in mind that many children have been on the wait lists since birth so the lists are VERY long.

*Required

Child Information
*Child Name

 

*Child Gender

 

*Birthdate

 

 
Family Contact
*Family

 

*Child Address

 

*Contact Phone

 

*Email

 

*Preferred Contact:

 

Parent/Guardian 1 Business Address

 

Parent/Guardian 2 Business Address

 

Emergency Contact
Emergency Contact #1

 

Emergency Contact #2

 

Emergency Contact
Sibling #1

 

Sibling #2

 

Sibling #3

 

Sibling #4

 

Sibling #5

 

Sibling #6