Form no. 04233CCDC CS-EDU Rev. 12/2015
Application for Enrollment
Child Care Development Center
Ada Ardmore
Child’s name:
First MI Last Suffix
Birth date or due date: Gender: Male Female Unknown
Names of persons with whom the child lives:
Address:
Home phone no.:
Father’s employer:
Work no.: ______________ Cell no.: ______________ Email address:
Mother’s employer:
Work no.: ______________ Cell no.: ______________ Email address:
Are you currently receiving Chickasaw Nation Child Care Assistance?
Yes No
Does your child currently have a citizenship certificate, CDIB or tribal membership?
Yes No Tribe:
Does parent possess a citizenship card, CDIB or tribal membership? Yes No
If yes, will the child be eligible for tribal citizenship/membership? Yes No
Are you a Chickasaw Nation employee? Yes No
If so, what division?
Is this child a foster child? Yes No
Is this child a CDC or Head Start sibling? Yes No
Does this child have any special needs? Yes No
If yes, please explain:
FOR OFFICE USE ONLY:
Date application received: Date enrolled:
Processing date: CDC employee:
Education Division / Child Care
222 Rosedale Road / Ada, OK 74820 / (580) 272-5398 / Fax (580) 272-2735
1001 Cottonwood Street / Ardmore, OK 73401 / (580) 222-2946 / Fax (580) 222-2947
