Application for Enrollment

*Child's Name:

*Child's Duedate:

*Child's Birthdate:

Child's Sex*:
Select an Option Male Female NA

*Desired enrollment date:

*Child's age at that time:

*Enrollment desired, days of week requested:

*Name:

*Home Address:

*Home Phone:

*Place of Work:

*Work Phone:

*Email:

Dartmouth College Affiliation

Department:

Hinman Box:

Percentage of fulltime employment by DC: