YORK TECHNICAL COLLEGE CHILD DEVELOPMENT CENTER

Application for Admission
 
Please complete all items on this form. Thank you.
 
Child's Name:   Date of Birth:       /     / Age:   Sex:  
           
Address:  
                                Street                                                             City                                                    State                              Zip
 
Parental Status

(Pertaining to The College)

 ____Tech Student/Major ____               ____Tech Faculty/Department ____

____Tech Staff/Area____                      ____ Other:  Please list_____________
 
Mother/Guardian's Name:   Social Security #:  
  First                    Middle                                         Last
   
Address:  
                                     Street                               City                                       State                   Zip Code             Home Phone #
   
Place of Employment:  
                                              Company/Organization                                                      Address                                        Phone #
   
If Applicable: Cell phone #   Pager #  
       
Father/Guardian's Name:   Social Security #:  
  First                                    Middle                             Last    
 
Address:  
                                   Street                                                City                     State                    Zip Code                         Phone #
 
Place of Employment:  
  Company/Organization                Address                                                                          Phone #
 
If Applicable: Cell phone #   Pager #  
 
List previous child care experience:  
   
What do you hope to gain for yourself and your child from our Child Development Program?

 
 

Where or how did you hear about our Program?

 

 
Please make checks payable to York Technical College, and return to the following address:

Child Development Center--Registration, York Technical College, 452 South Anderson Road, Rock Hill, S.C. 29730
Office Use Only

Date Received

Application Fee

Registration Fee
 

______________________________________________________________________

College Site