Enrollment Request

Thank you for your interest in our program. Please take the time to complete the questions listed below to join our waitlist. Once you have completed this form we will review your information and contact you upon availability. If you have questions regarding our program please email us at lechilddevelopment@gmail.com or contact our center at 412-205-3287.

Caretaker Information

First name

Last name

Email

Phone

Selecting your Funding Source

If other please provide more information:

When are you looking to start childcare?

What is the best DROP OFF time for you?

My times will vary

What is the best PICK UP time for you?

My times will vary

Child Information

Child 1

Birthday

Month

Day

Year

Special Needs

Development & Learning Needs

Medical or Physical Needs

Service Plans or Support

None of the above

If you selected any of the above, please describe your child's needs, current supports, and anything we should know to provide the best care possible.

Child 2

Birthday

Special Needs

Development & Learning Needs

Medical or Physical Needs

Service Plans or Support

None of the above

If you selected any of the above, please describe your child's needs, current supports, and anything we should know to provide the best care possible.

Child 3

Birthday

Special Needs

Development & Learning Needs

Medical or Physical Needs

Service Plans or Support

None of the above

If you selected any of the above, please describe your child's needs, current supports, and anything we should know to provide the best care possible.

Child 4

Birthday

Special Needs

Development & Learning Needs

Medical or Physical Needs

Service Plans or Support

None of the above

If you selected any of the above, please describe your child's needs, current supports, and anything we should know to provide the best care possible.

Thanks for submitting!
We look forward to be in touch.

Enrollment Request

Caretaker Information

Child Information

Thanks for submitting! We look forward to be in touch.

Thanks for submitting!
We look forward to be in touch.