UCSD Early Childhood Education Center - Application for Childcare

Application For Child Care (Please submit a separate application for each child)

Child
Child's First Name:
Child's Last Name:
Date Your Child Needs Care:	(mm/dd/yyyy)
Child's Gender:
Child's Date of Birth:	(mm/dd/yyyy)

Name(s) of your other children currently enrolled at UCSD child care:
	First Name Last Name
Child 1:
Child 2:
Child 3:

Are you a single parent?	YesNo
Are you eligible for a PELL grant?	YesNo
Are you interested in applying for subsidized child care?	YesNo

Parent/Guardian 1
First Name:
Last Name:
Home Phone Number:
Work Phone Number:
Address:
City:	State: Zip:
Employment Status:
UCSD Affiliation:



Submitting this application places your child on a waiting list pending receipt of your non-refundable application fee of $35 for each child. Your child will be considered by the date of application as space becomes available. [If you meet the income guidelines for subsidized child care, you do not need to submit an application fee.]

After submitting your on-line application, mail your check, payable to UC Regents, to the address below.

University of California Early Childhood Education Center, MC 0962 9500 Gilman Drive La Jolla, CA 92093-0962

Parents/Guardians are responsible for keeping contact information (phone number and address) current. If we cannot reach you, your child(ren) will be removed from the waiting list. To change your phone number or address, call our office at (858) 552-2500.

If you would like to receive an e-mail confirmation, please enter your e-mail address here:



© 2003, Regents of the University of California. All rights reserved