Instructions: Please fill out each section.  When you click submit, your application will be automatically received at the Child Learning Center and your child will be placed on the Waiting List. 
Today's date  xx-xx-xxxx
First date of  attendance  xx-xx-xxxx
  
Child Name 
Birthdate  xx-xx-xxxx Age 
Parent Information
Father Name 
Home Phone 
Cellular Phone 
E-mail address 
Place of Employment 
Work No. 
Home Address
Father is an  APSU Student  APSU Staff  APSU Faculty   APSU Alumni
Mother Name 
Home Phone 
Cellular Phone 
E-mail address
Place of Employment 
Work No. 
Home Address  
Mother is an  APSU Student  APSU Staff  APSU Faculty   APSU Alumni
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