Faculty/Staff: Re-Enrollment Will Occur Each Autumn

ASUM Child Care Preschool Center Enrollment Application & Contract Note: Completing this application does not guarantee enrollment Application due by June 1 st for Autumn semester enrollment. Autumn semester enrollment will begin June. Spring semester enrollment will begin November. Summer Enrollment will begin in April 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______Staff ______(see faculty/staff information on website)

_____ Yes _____No _____(initial if “Yes”) I am receiving U of M financial aid to assist me with payment of my child care services and 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 _____(Initial if yes) I am participating in a State or Agency program that will be assisting me with payment of my child care services and understand I will be responsible for any balance not paid by the State or Agency Program. Name of Agency/Program______

*********************************** Indicate 1st, 2nd, 3rd Choice if Applicable Centers may combine during breaks, and summer. ___Early Learning I ___Children’s Learning I ___Children’s Learning II ___Early Learning II (Infant) McGill Hall 001A McGill Hall 001 Craighead 115A U. Villages Craighead 111A U. Villages Ages 2 yrs.-3 yrs. Ages 3-6 yrs. Ages 3-6 yrs. Ages 1 month-23 months (preference given to 5 days/week) Completely toilet trained Completely toilet trained. (preference given to 5 days/week) 2 day enrollment minimum (preference given to 5 days/week) (preference given to 5 days/week) 2 day enrollment minimum Student Rate--$34.50 per day 2 day enrollment minimum 2 day enrollment minimum Student Rate--$36.50 per day Faculty/Staff Rate--$790per mo. Rate--$34.50 per day Rate—Full Day--$34.50 per day Faculty/Staff Rate--$835 per mo. Pro-rated on # of days. Faculty/Staff Rate--$790per mo. Faculty/Staff Rate--$790per mo. Pro-rated on # of days Pro-rated on # of days Pro-rated on # of days

M T W R F M T W R F M T W R F M T W R F

Upon submitting this application/contract you are agreeing to all policies, fees, deadlines etc. as indicated in the Parent Handbook Contract posted on the program’s web page at www.umt.edu/childcare .

Signature ______Date ______Preferred Start Date______

Return this SIGNED Page to ASUM Child Care Preschool and Family Resources University Center Room 119, 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!