Waiting List Application General InformationChild's Full Name*Child's Date of Birth or Due Date* MM slash DD slash YYYY Sex* Female Male Both Parents' Full Names*Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Email Address* Parent InformationName of Parent*Occupation*Full Time or Part Time* F/T P/T Work Phone*Current UConn Affiliation?* Yes No If yes, what department*Union* UCPEA AAUP AFSCME Student* Yes No If yes, Full Time or Part Time* F/T P/T What Department?*Parent2 InformationName of ParentParent 2 Email AddressOccupation*Full Time or Part Time* F/T P/T Work Phone*UConn Affiliation* Yes No If yes, what department*Union* UCPEA AAUP AFSCME Student* Yes No If yes, Full Time or Part Time* F/T P/T What Department?*Other InformationI would like to enroll my child* F/T (5 full days per week) P/T (5 mornings/week - preschool only) What month and year do you want your child to start at the Child Labs?*Child's Ethnic Background* American Indian/Alaskan Native Asian/Pacific Islander Black, not of Hispanic Origin White, not of Hispanic Origin Hispanic Multi-ethnic Special Needs of Child (if any)Approximate Family Yearly Income* $50,000 and below $51,000-$150,000 $151,000 and above 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. If you would like to apply for one of these slots, please enter your Yearly Adjusted Gross Income (parents' combined incomes)Number of Family Members*What do you hope your child will gain from attending the Child Development Labs?*EmailThis field is for validation purposes and should be left unchanged.