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Dartmouth College Child Care Center
21 Reservoir Rd., HB 6233
Hanover, NH 03755
(603) 646-6610
(603) 646-3232 Fax
DCCCC@dartmouth.edu

Home > Enrollment >

Application for Enrollment

Required fields*

Child's Information *Child's Name:

*Child's Birthdate/Duedate:

*Child's Sex: M: F: NA:

*Desired enrollment date:

*Child's age at that time:

*Enrollment desired, days of week requested:

Parent/Guardian 1 Information *Name:

*Home Address:

*Home Phone:

*Place of Work:

*Work Phone:

*Email:

Dartmouth College Affiliation Department:

Hinman Box:

Percentage of fulltime employment by DC:

Check all that apply

Faculty:
Research Assistant: please indicate A, B, or C
Exempt:
Non-Exempt:
Service Student:
Non-DC:

Parent/Guardian 2 Information Name:

Home Address:

Home Phone:

Place of Work:

Work Phone:

Email:

Dartmouth College Affiliation Department:

Hinman Box:

Percentage of fulltime employment by DC:

Check all that apply

Faculty:
Research Assistant: please indicate A, B, or C
Exempt:
Non-Exempt:
Service Student:
Non-DC:

Electronic Signature: Checking this box and submitting this form is the legal equivalent of your signature.

Last Updated: 11/15/11