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Faculty/Staff Enrollment Form
Please print this
form and submit it to the Children's Learning and Care Center, Swart Hall, UW
Oshkosh, Oshkosh, Wisconsin 54901-8632.
Date of
Application:___________________ First
day of attendance:__________________
Child's name:_______________________________
Birthdate:_______________________
Father:__________________________________
Address:_______________________
City:_____________ Zip:_________ Phone # __________________
Business:______________________________
Phone #______________________
Hours of
Work:___________________________________________________________________
Mother:___________________________________
Address:____________________________
City:___________ Zip:___________ Phone #____________ Business:_______________________________
Phone # _______________________
Hours of
Work:____________________________________________________________________
Please indicate
the days and times you will be needing child care on the back of this form.
List persons who are authorized to call for your child:
1.______________________
Phone:______________2.____________________ Phone:_______________
Address:_________________________________
Address:_____________________________________
Relationship to child:_______________________ Relationship
to child:___________________________
Name, Address and
Phone of Persons Who will Care for Your Child In Case of An Emergency (If
something happens to the parents). If no one is listed, legally we must
turn the child over to the Department of Social Services after Center hours.
1.____________________
Phone:______________ 2.____________________ Phone:_______________ Address:___________________________________Address:___________________________________
Relationship to
child:_________________________ Relationship to child:_________________________
Child's Physician_________________________Address:____________________
Phone:________________
List Child's Special
Needs (allergies, behaviors, speech,
feeding,etc.)_______________________________ __________________________________________________________________________________________
I give my permission to the
Children's Center Staff to take my child to a physician in the event of an
emergency when I cannot be reached.
I understand the Children's Center
does provide liability insurance for the staff and all volunteers through the
University, but my child is NOT covered by accident insurance while at the
Children's Center.
I understand that I am responsible to pay for all times for which
I am registered whether or not my child is present at the Center, Covering
the entire term for which I have enrolled (Semesters Interim or Summer
Sessions).
I understand that I must pay a
$2.50 non-refundable registration fee per family at the time of registration each
term - semesters and summer. This fee must be paid for interim only if
NOT scheduled during the regular semester.
Signature:________________________________ Date:_____________________
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