Nash Community College
Betsy B. Currin Child Development Center
Waiting List Application
Date of Application________________________________________
Name of Child____________________________________________
Birth date____________ Age Group___________ Sex___________
Home Address___________________________________________
Home Telephone Number__________________________________
Name of
Mother/Guardian________________________________________
Employer_______________________ Work Phone______________
Name of
Father/Guardian_________________________________________
Employer_____________________ Work Phone________________
Are you a NCC Staff Member_______? NCC Student____________?
Please complete and return to:
The Betsy B. Currin Child Development Center
Nash Community College
Attn: $QJHOD1LHYHV
522 N. Old Carriage Road
Rocky Mount, NC 27804
Or email to
DQLHYHV@nashcc.edu