Childcare Application

Children are registered on a first come, first served basis. Your application is not complete until we receive your $15 registration fee.

The following information will be e-mailed to a CLC employee. Please remember that email is not a secure medium. Do not sent personal or sensitive information.

Application Information

1. Child's Age: 15 months to 3 years (Green Room) 3 to 5 years (Red Room)
2. Today's date: (mm/dd/yy)
3. I need to enroll my child by:
4. Semester: Fall Spring Intersession Summer

Child’s Information

1. First Name
2. Middle Initial
3. Last Name
4. Gender male female
5. Birthdate (mm/dd/yy)

Applicant’s Information

1. First Name
2. Middle Initial
3. Last Name
4. Relationship to child:
5. Email Address
6. Address
7. City
8. State
9. Zip Code
10. County
11. Area code and home phone
12. Area code and work phone
13. Best day and time to reach you
14. I am a: MCC studentMCC employee
15. I am receiving Financial Aid. Yes No
16. If yes, what type of Financial Aid?
17. I am taking the following classes: Credit ESL GED Fitness Center Continuing Education (noncredit)
18. How many credits?
19. Please check the days you need your child enrolled in the Children's Learning Center and enter the hours you need. Scheduling is done ten minutes to the hour. For example, if you are in class from 1 to 2:20 p.m., you would contract from 12:50 to 2:50 p.m.
20. Monday Time
21. Tuesday Time
22. Wednesday Time
23. Thursday Time
24. Friday Time

Confirmation Code: 201228195242666
Enter the Confirmation Code