TCC Child Development Centers Enrollment Form

Interested in enrolling at a Tidewater Community College Child Development Center? Please fill out the information and join the list. For more information about the program email cstreeter@tcc.edu or visit tcc.edu/childcare

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About You

Your Name(Required)

First Last

Are you a full-time student?(Required)

Yes

Third Choice

Do you have a current FAFSA on file for the Academic Year?(Required)

Yes

Third Choice

Are you Pell Grant recipient?(Required)

Yes

Third Choice

What Campus do you attend class?(Required)

Chesapeake

Norfolk

Portsmouth

Virginia Beach

What city do you reside in?(Required)

Are you a Child Care Access Means Parents in School (CCAMPIS) recipient without a childcare slot in the community?(Required)

Yes

Third Choice

What hours of the day would you typically need childcare?(Required)

Ages of your child/children?(Required)

Which location are you interested in?(Required)

Chesapeake

Norfolk

Portsmouth

Virginia Beach

Please select your choice as we expand Childcare Centers.

What semester do you need childcare?(Required)

Fall 2023

Spring 2024

Summer 2024

Requested start date?(Required)

Tell us about your family

Please share information about you and your family.

Child's Full Name(Required)

Child's Date of Birth(Required)

Child's Address(Required)

Street Address Address Line 2 City ZIP Code

Mother's Full Name(Required)

Mother's Address(Required)

Street Address Address Line 2 City ZIP Code

Mother’s Place of Employment(Required)

Father's Full Name(Required)

Father's Address(Required)

Street Address Address Line 2 City ZIP Code

Father’s Place of Employment(Required)

Preferred Method of Contact

Phone

Your Email Address(Required)

Email Address Confirm Email Address

Does your child have any known health problems? If so, please list below(Required)

Is your child prescribed a daily medication(s)? List below.(Required)

Does your child have any known allergies? List below.(Required)

Do you have any concerns about your child's development.(Required)

Please comment below any other information or special instructions to care for your child.