Student Admission Application

Complete this enrollment form to register your student with CDI. All information is confidential and reviewed by our enrollment coordinator.

Disclaimer: All applications are subject to review and remain in pending status until approved by an administrator. Applications that are incomplete or contain inaccurate or unverifiable contact information may be automatically rejected. Please ensure all required information is complete and accurate before submitting your application. Thank you for your understanding.

Student information

First name *

Last name *

Date of birth *

Gender

Grade / age group

Program of interest

School

Home address

Street address

City

State

ZIP

Medical information

Allergies

Current medications

Medical conditions

Physician name

Physician phone

Insurance provider

Policy number

My student has an active IEP or 504 plan

Primary parent / guardian

Full name *

Relationship

Phone *

Email *

Employer

Second parent / guardian (optional)

Full name

Relationship

Phone

Emergency contact

Full name *

Relationship

Phone *

Authorized pickup persons

Only these individuals will be permitted to pick up your student. Photo ID required at pickup.

Consents & acknowledgements

Emergency medical treatment consent *I authorize CDI staff to seek emergency medical treatment for my student if I cannot be reached.Parent handbook & code of conduct *I have received and agree to the CDI parent handbook, attendance policy, and code of conduct.Field trip permissionI grant permission for my student to participate in supervised CDI field trips and off-site activities.Photo / media releaseI grant permission for CDI to use photos or video of my student in non-commercial program materials.

Additional notes

Signature

By typing your full legal name below, you certify that all information provided is accurate and you have the legal authority to enroll this student.

Parent / guardian full legal name *