Our Programs

The Parent-Child Development Center welcomes people of all races, religions, geners, and national origins.

Parent-Child Development Center

Mandatory field Child's Name:*
Mandatory field Child's Date of Birth*
Child's Gender	Male Female
Mandatory field Child's Ethnicity*	Hispanic Not Hispanic
Mandatory field Child's Race*	White Black Asian Am. Indian/Alaskan Hawaiian/Pacific Islander Multi-Race
Mandatory field Country of Origin*
Does this child have a documented special need or disability?	Yes No
Does this child have allergies/asthma?	Yes No
Does this child take medication regularly?	Yes No
Does this child suffer from life-threatening allergies/asthma?	Yes No
If you answered yes, please describe special needs and/or allergies and medications used
Mandatory field 1st Parent/Guardian Name:*
Mandatory field Parent/Gaurdian's Date of Birth*
Parent/Guardian Employer:
Mandatory field Parent/Guardian Education Level*	0-8th Grade 9-12th Grade 9-12th Grade GED/HS 12+ Degree
Mandatory field Parent/Gaurdian's Ethnicity*	Hispanic Not Hispanic
Mandatory field Parent/Gaurdian's Race*	White Black Asian Am. Indian/Alaskan Hawaiian/Pacific Islander Multi-Race
Mandatory field Country of Origin*
Mandatory field 2nd Parent/Guardian Name:*
Mandatory field 2nd Parent/Gaurdian's Date of Birth*
2nd Parent/Guardian Employer:
Mandatory field 2nd Parent/Guardian Education Level*	0-8th Grade 9-12th Grade 9-12th Grade GED/HS 12+ Degree
2nd Parent/Gaurdian's Ethnicity	Hispanic Not Hispanic
2nd Parent/Gaurdian's Race	White Black Asian Am. Indian/Alaskan Hawaiian/Pacific Islander Multi-Race
Mandatory field 2nd Parent/Guardian's Country of Origin*
Mandatory field Parent/Guardian Street Address*
Mandatory field City:*
Mandatory field State:*
Mandatory field Zip Code:*
Mandatory field Home Phone/Contact Number*
Current Total Monthly Income:
Sources of Income:
Last Year's Total Come:
Last Year's Sources of Income:
Are you currently receiving any child support?	Yes No
Hours in Need of Child Care
Mandatory field Are you interested in learning about the Home-Based home visiting program?*	Yes No
How do you plan to transport your child to care?
Are you eligible for voucher subsidy through TAFDC?	Yes No Not Sure
Mandatory field Does a parent/guardian have a documented disability (physical or emotional), causing the need for full time care?*
Please list the names and ages of other children living in your household: