Waiting List Application General InformationChild's Full Name*Child's Date of Birth or Due Date* Sex*FemaleMaleBoth 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/TP/TWork Phone*Current UConn Affiliation?*YesNoIf yes, what department*Union*UCPEAAAUPAFSCMEStudent*YesNoIf yes, Full Time or Part Time*F/TP/TWhat Department?*Parent2 InformationName of ParentOccupation*Full Time or Part Time*F/TP/TWork Phone*UConn Affiliation*YesNoIf yes, what department*Union*UCPEAAAUPAFSCMEStudent*YesNoIf yes, Full Time or Part Time*F/TP/TWhat Department?*Other InformationI would like to enroll my child*F/T (5 full days per week)P/T (5 mornings/week - preschool only)Child's Ethnic Background*American Indian/Alaskan NativeAsian/Pacific IslanderBlack, not of Hispanic OriginWhite, not of Hispanic OriginHispanicMulti-ethnicSpecial Needs of Child (if any)Approximate Family Yearly Income*$50,000 and below$51,000-$150,000$151,000 and aboveFamilies 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?*CommentsThis field is for validation purposes and should be left unchanged.