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Child Enrollment Form

This form is an indication of interest only in attending the University of Wisconsin-Children's Center. Completing this form does not mean your child has been accepted into the program.

Complete the Children's Center Interest Form below online now, or open a printable version of the Enrollment Interest Form in PDF format. Call Becky at 715-836-2178 if further information is needed.


Today's Date:

Child's Full Name:

Child's Gender:                   

Child's Birthdate:

Parent/Guardian's Name:

Address:

City:

State:     Zip Code:

Home Phone:

Work or Cell Phone:

E-mail Address:

Parent is...
                   

Are you interested in Full or Part Time child care?
         

Does your child have any special needs?

When would you be interested in starting at the Children's Center?

  

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