Child Care Application form Simply fill out the on-line “Application” form below and send it directly to us over the internet. That’s all you need to do to get the process going. Name First Last Date of Request MM slash DD slash YYYY Mother's Name First Last Father's Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone Work Phone Cell Phone Email Name of Children to be EnrolledName (First & Last)Date of BirthAge Name of Children to be EnrolledName (First & Last)Date of BirthAge Referred ByHow did you find out about our center?Child Care ResourcesNCDC WebsiteNewspaperCurrent/Former NCDC ClientGoogle SearchCare.comIndeed.comDays Requested for Care Monday Tuesday Wednesday Thursday Friday Arrival : Hours Minutes AM PM AM/PM Departure : Hours Minutes AM PM AM/PM Requested Start Date MM slash DD slash YYYY Δ