Application Form for Enrollment
Virginia Marx Children's Center

Child's Name (first and last):   Nickname:

Birth Date (MM/DD/YY)      Gender: Female Male
Address: 
City/Town:    State:    Zip 

About You
Parent's Name:
Address: 
City/Town:    State:    Zip 
Home Phone   Work Phone  
E-Mail Address
Occupation: Employer's Name:
Address: 
City/Town:    State:    Zip 
Parent's Name:
Address: 
City/Town:    State:    Zip 
Home Phone   Work Phone  
E-Mail Address
Occupation: Employer's Name:
Address: 
City/Town:    State:    Zip 

Are you:
Westchester Community College:
 
Future Student    
Current Student Full Time    Part Time  
Staff Department: Extension:
Faculty Department: Extension:
Hours Requested:  Full-time   Part-time 
(Student parent - minimum of 20 hours per week)
OR A
Community Parent:  
About Enrollment:
Days Requested : Monday   Tuesday   Wednesday   Thursday   Friday
A non-refundable registration fee registration fee is charged for the enrollment of each child:

$75.00 for children of Westchester Community College staff, Westchester Community College faculty, County Employees & Community Parents

$30.00 for children of Westchester Community College student-parents

 

Please click the Submit button ONCE ONLY and wait for the “thank you” page to appear.

 

  

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