Childrens Place Application Form – Fill Out and Use This PDF

UMD Children’s Place

Application for Admission

Please return this form with the non-refundable $30 application fee

to add your child’s name to the waiting list (fee is $45 for multiple children)

Child’s Name: _____________________________________ Date of Birth ____________________

*Last

First

Middle

Actual or Anticipated

*Please print the child’s last name. S/he will be listed by this name.

Address _____________________________________ City ______________________ Zip _______

	Does this child have an identified special need *? Yes ____ No ____	*UMD Children’s Place is
		an inclusive program

PREFERRED START DATE ________________________________ Age on start date ________

Please enter a complete date: MONTH

DAY

YEAR

(in months)

When your child’s name reaches the top of the list, we will call you for any age appropriate opening in the schedule you have indicated on the reverse of this form occurring 30 days prior to or any time after your indicated start date. ***Preference is given to UMD faculty, students and staff.

If you are offered and decline the enrollment date noted above, or the schedule requested on the reverse side of this form, your child’s name will go to the bottom of

the waiting list.

Parent or Guardian 1:

Name____________________________________________________________________________

Address_____________________________City____________________ State ______ Zip_______

Phone numbers: (H)____________________(W)__________________(Cell)___________________

Email address _____________________________________________________________________

Parent or Guardian 2:

Name_____________________________________________________________________________

Address_____________________________City_____________________ State ______ Zip_______

Phone numbers: (H)____________________(W)___________________(Cell)___________________

Email address ______________________________________________________________________

UMD Employee _____ UMD Student _____ No UMD Relationship at this time ____

I (We) understand that this application does not guarantee enrollment in the UMD Children’s Place.

Signed	Date
For office use only:	*Pre-enrollment conference held __________ Appl. recv’d. on __________

Non-refundable Appl. Fee paid on ___________ Check # ___________ Amt. Paid ____________

Child enrolled ______________________ Child withdrawn __________________________________

260 Kirby Plaza 1208 Kirby Drive Duluth, MN 55812 218.726.6727 FAX 218.726.6654

UMD Children’s Place

Application for Admission

Child’s Name: _____________________ Age Group: Infant____ Toddler____ Preschool____

Enrollment Options ** Please note that enrollment options are for FULL DAYS only and priority is for full-time, full year enrollment.

Full time

____	Full Time (Monday through Friday full days; full year)
____	Full Time (Monday through Friday full days; partial year)
	Care requested from ____________________through __________________
	Date	Date
Part-time
____	Monday, Wednesday, Friday (Full Days; full year)
____	Monday, Wednesday, Friday (Full Days; partial year)
	Care requested from ____________________through __________________
	Date	Date
____	Tuesday and Thursday (Full Days; full year)
____	Tuesday and Thursday (Full Days; partial year)
	Care requested from ____________________through __________________
	Date	Date

Rates (as of 7/01/12 and subject to change)

Infant Care:	Monday through Friday	$210/week
6 wks – 16 months	Monday/Wednesday/Friday	$139/week
	Tuesday/Thursday	$101/week
Toddler Care:	Monday through Friday	$190/week
(16 mo. – 33 mo.)	Monday/Wednesday/Friday	$127/week
	Tuesday/Thursday	$ 93/week
Pre-school Care:	Monday through Friday	$185/week
(33 mo. – 1st day K)	Monday/Wednesday/Friday	$124/week
	Tuesday/Thursday	$ 91/week

A 10% discount is given to families with multiple children enrolled.

I/We understand that tuition is billed in four week increments and a statement with due date will be issued. Families receiving childcare assistance are responsible for all charges not paid by the funding source. A late fee of $25 will be applied to any account where payment is not received by the due date. Delinquent accounts will be turned over to a collection agency, and enrollment will be terminated. Accounts in collection will be assessed up to 50% of the balance to cover collection costs. We charge for all absences including illness or vacation. If a child is withdrawn from the program, written notification must be given to the director. Tuition is charged for four weeks following this written notification. Changes to an enrollment schedule will only be made if space is available.

Signed __________________________________________________ Date _______________

Notify us of ANY changes in your enrollment choice. When offered a placement, it is based on this information. If you do not accept the enrollment option offered, your child will go to the bottom of the waiting list. All changes must be submitted in writing.

260 Kirby Plaza 1208 Kirby Drive Duluth, MN 55812 218.726.6727 FAX 218.726.6654