| Waiting
List Application Form |
| Child's
Full Name* |
|
Date of
Birth*
(or expected date due) |
|
| Sex* |
M
F |
| Both Parents'
Full Names* |
|
| Street* |
|
| Town
and State* |
|
| Zip
Code * |
|
| Home Phone* |
|
| E-mail
Address* |
|
| University
of Connecticut Affiliated? |
Yes
No What Dept.?
|
| Parent Information |
| Name of Parent and Occupation |
|
| Full Time
or Part Time |
F/T
P/T
Work Phone #
|
| Student |
Yes
No
F/T
P/T |
| What Dept.? |
|
| Union |
UCPEA
AAUP
AFSCME
Other |
| Parent Information |
| Name of Parent and Occupation |
|
| Full Time
or Part Time |
F/T
P/T
Work Phone #
|
| Student |
Yes
No
F/T
P/T |
| What Dept.? |
|
| Union |
UCPEA
AAUP
AFSCME
Other |
| Other
Information |
| Would you
like your child enrolled in the Child Labs |
Full time (5 full days a week)
Part time (5 mornings a week, preschool only) |
| Child's Ethnic Background* |
American Indian/Alaskan Native
Asian/Pacific Islander
Black, not of Hispanic origin
Hispanic
White, not of Hispanic origin
|
|
Special
Needs of Child (if any) |
|
Families who have yearly incomes under $72,000 may qualify
for lower tuition rates. The Director must receive verification
of income (two current paycheck stubs) from those applying at the time of registration. Please check below if you wish
to apply for one of these slots. |
| Yearly Adjusted
Gross Income: (Parents combined income) |
$30,999 and under
$31,000-$43,999
$44,000-$57,999
$58,000-$72,000 |
| Number of
family members |
|
| What do you hope your child will gain from attending the Child Development Labs?* |
|
| |
