Enrollment Application

Fill out and submit the enrollment application below. You will be contacted after submission as time permits to discuss your enrollment application submission.

Click to open a printable Enrollment Application

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Your enrollment application has been submitted! You will be contacted as time permits.

Enrollment Date Requested (YYYY-MM-DD)

Child #1 Last Name

Child #1 First Name

Child #1 Gender

Child #1 Birth Date (YYYY-MM-DD)

Child #1 Special Needs

Child #2 Last Name

Child #2 First Name

Child #2 Gender

Child #2 Birth Date (YYYY-MM-DD)

Child #2 Special Needs

Child #3 Last Name

Child #3 First Name

Child #3 Gender

Child #3 Birth Date (YYYY-MM-DD)

Child #3 Special Needs

Child(ren) Live(s) With

Other Explanation

Child(ren)’s Address (Ex: 59 Pomeroy Street, Apt. 3, Cortland, NY 13045)

Note: Parent/Guardian #1 will be contacted after application submission.

Parent/Guardian #1 Last Name

Parent/Guardian #1 First Name

Parent/Guardian #1 Address (Ex: 59 Pomeroy Street, Apt. 3, Cortland, NY 13045)

Parent/Guardian #1 Cell/Home Phone Number

Parent/Guardian # 1 Email Address

Parent/Guardian #1 Employer Name

Parent/Guardian #1 Work Phone Number

Parent/Guardian #1 School District

Parent/Guardian #2 Last Name

Parent/Guardian #2 First Name

Parent/Guardian #2 Address (Ex: 59 Pomeroy Street, Apt. 3, Cortland, NY 13045)

Parent/Guardian #2 Cell/Home Phone Number

Parent/Guardian # 2 Email Address

Parent/Guardian #2 Employer Name

Parent/Guardian #2 Work Phone Number

Parent/Guardian #2 School District

Child Care Need
(Note: Priority will be given to families needing full time enrollment)

Hours of the Day Child Care Needed

Chose Tuition Payment Information (check all that apply)(required)

I will be paying the full cost of tuition for my child(ren)

I request tuition assistance

I receive additional support through DSS, child support, etc.

Gross Annual Income (if tuition assistance chosen above)

Total Number of Members in Household (if tuition assistance chosen above)

Caseworker’s Name (if support through DSS chosen above)

Any Other Pertinent Details for Enrollment

By clicking the submit button below, I acknowledge that someone at Cortland Child Development Center will contact me in a timely manner (usually within a week). I also acknowledge that the submission of this application does not guarantee me a spot within any program and does not get me automatically added to any waiting lists.