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First Parent/Guardian Information

Parent/Guardian's Last Name (* required)

Parent/Guardian's First Name (* required)

Parent/Guardian's Email (* required)

Parent/Guardian's Affiliation with IU Indianapolis: (* required)

IU Employee/Student/Faculty
IU Health Employee
General Public

Parent/Guardian's Employer: (* required)

Parent/Guardian's Address (* required)

Address Line 1:

Address Line 2:

City:

State:

ZIP Code:

Home Phone (* required)

Cell Phone

Work Phone (* required)

Second Parent/Guardian's Information

Second Parent/Guardian's Last Name

Second Parent/Guardian's First Name

Second Parent/Guardian's Email

Second Parent/Guardian's Affiliation with IU Indianapolis:

IU Employee/Student/Faculty
IU Health Employee
General Public

Second Parent/Guardian's Employer:

Second Parent/Guardian's Address

Address Line 1:

Address Line 2:

City:

State:

ZIP Code:

Second Home Phone

Second Cell Phone

Second Work Phone

Special Accommodations

The Center for Young Children is an accessible facility, please list any special accommodations below. (* required)

Payment

Have you applied for/are you applying for a subsidy through one of the following? (* required)

On My Way Pre-K
CCDF (Child Care and Development Fund)
None

Have you paid the $25 non-refundable filing fee? (Enter Confirmation Number Below) (* required)

Yes
No