LCP: Enrollment Interest Form

Your name *

Email address *

Phone number *

Child(s) 3+ Is your child potty trained? *

Yes- Needs no assistance

No- Still wears a diaper or pull up

In the process -Still wears a diaper or pull up sometimes

Household members

For infants-5 years old (not Kindergarten), please include the child(s) name and DOB.
For School aged child(ren), state the name, DOB, grade, and school.

How will you be paying? *

Private Pay

CCDF

For CCDF families, what is the status of your child's voucher

My CCDF is active. I have funding, and CCDF is requesting for Provider Form to be completed and submitted.

I am on the waitlist, and I am waiting to receive funding.

I do not have CCDF, but I want information on how to apply.

When are you interested in enrolling your child(ren) *

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