| Date
of Application: |
For:
Fall or Spring Semester; Fall or Spring Interim; Summer (Circle One) |
| Have
you applied for financial aid? Yes/No |
At: University Financial
Aids Office______Other Agency______
AgencyName:_________________________Phone#:____________ |
I
give my permission for the Children's Center to verify my application
for financial aid.
Signature:________________________________________________ |
Child's
Name:
|
Birthdate: |
| Father: |
| Student ID#____________Address:______________________________City:________________Zip______Phone#___________ |
| Business:______________________________Work
Times:________________Phone#:___________
|
| Mother: |
| Student ID#____________Address:______________________________City:________________Zip______Phone#___________ |
| Business:______________________________Work
Times:________________Phone#:___________ |
| Persons
Who Are Authorized to Call for Your Child: |
| 1. Name: |
Phone#: |
| Address:______________________________________________City:________________Zip______ |
| Relationship
to child: |
2. Name: |
Phone#: |
| Address:______________________________________________City:________________Zip______ |
| 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. Name: |
Phone#: |
| Address:______________________________________________City:________________Zip______ |
| Relationship
to child: |
Child's Physician____________________Address:_________________________________Phone#:__________ |
| List
of 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 that if I am student teaching, doing an
internship, or other field placement during the spring semester and my
spring semester break does not coincide with that of the University, the
Children's Center Director must be aware of this by the end of the second
week of the semester in order to curtail billing for that week.
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 also understand that drop time schedule changes are
allowed only during the first week (for 14 week and first 7 week classes)
and during the 8th week for the second 7 week classes. 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:________________________________ |