ASUM Child Care Preschool Center Enrollment Application

O ffice Use
WL Date___________
Time Called_____________
Time Called_____________
Time Called_____________
Conf____________________ ASUM Child Care Preschool Center Enrollment Application & Contract Note: Completing this application does not guarantee enrollment Autumn semester enrollment will begin June.
Summer Enrollment will begin in April. Spring semester enrollment will begin November.
Faculty/Staff: Re-enrollment will occur each Autumn.
Students: This Application is for Autumn/Spring/Summer of
Year
( Please circle semester above )
Parent___________________________________________________________________________ ID#___________________________________
Local Address __________________________________________________ City _________________ St _________ Zip ___________________
1st Parent’s Email ____________________________________________________________ Daytime Phone _____________________________
2nd Parent’s Email ____________________________________________________________ Daytime Phone ____________________________
Child’s Name _____________________________________________________ Age _____________ Birthdate __________________________
General Health ________________________________________________
Adequately Immunized for Age: Yes _________ No _________
Status: Student _______ Faculty________ _____ Yes
I am receiving U of M financial aid to assist me with payment of my child care services.
_____No
Staff _______ (see faculty/staff information on website) _____(initial if above is “Yes”), I understand that the full balance for the semester as contracted will be put on my account at the beginning of the semester and my financial aid will be used to pay my account. _____ Yes _____No I am participating in a State or Agency program that will be assisting me with payment of my child care services. Name of
Agency/Program_________________________________________________________
_____(Initial if above is yes), I understand I will be responsible for any balance not paid by the State or Agency Program. st
***********************************
rd Indicate 1 , 2nd, 3 Choice if Applicable summer.
Centers may combine during breaks, and ___Early Learning I
McGill Hall 001A
Ages 19 mo.-3 yrs.
2 day enrollment minimum
Student Rate--$32 per day
Fac/Staff/Com. Rate--$720per mo.
Pro-rated on # of days.
___Early Learning II
Craighead 111A U. Villages
Ages 19 mo.-3 yrs.
2 day enrollment minimum
Rate--$32 per day
Fac/Staff/Com. Rate--$720 per mo.
Pro-rated on # of days
___Children’s Learning I
McGill Hall 001
Ages 3-6 yrs.
Completely toilet trained
2 day enrollment minimum
Rate--$32 per day
Fac/Staff/Com. Rate--$720 per mo.
Pro-rated on # of days
.
___Children’s Learning II
Craighead 115A U. Villages
Ages 3-6 yrs.
Completely toilet trained.
2 day enrollment minimum
Rate—Full Day--$32 per day
AM (7:30-12:30)--$25 per day
Hour-$6 per hr IF using at least 2
Full or AM days.
Fac/Staff/Com. Rate--$720 per mo.
Pro-rated on # of days
Choose a Minimum of 2 Days
Choose a Minimum of 2 Days
Choose a Minimum of 2 Days
M
M
M
Choose a Minimum of 2 Days
Write in AM/Full/or the hrs.
M
T
W
R
F
T
W
R
F
T
W
R
F
T
W
R
F
Upon submitting this application/contract you are agreeing to all policies, fees, deadlines etc. as indicated in the
Enrollment and Billing Contract posted on the program’s web page at www.umt.edu/childcare.
Signature ______________________________________________ Date _____________________ ID#__________________________________
Return this SIGNED Page to ASUM Child Care Preschool and Family Resources
UC Room 119, U of M
Missoula, MT 59812
Fax (406) 243-2531
Email [email protected]
For more information please call (406)243-2542 or go to www.umt.edu/childcare. Thanks!