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Waiting List Parent Name Date Street Address City State Zip Home Phone Work Phone Student Name of School Place of Employment Date of Care Needed Full-Time Care Part-Time Care Child's Name Child's Birth Date Scholarship Requested (Title XX, Hamilton County, 4 C's, etc. ) Yes No Please return with $50.00 (non-refundable) registration fee to: UC Child Care Center, Inc. 3310 Ruther Avenue Cincinnati, Ohio 45220 (513) 961-2825

UC Child Care Center, Inc. University of Cincinnati phone (513) 961-2825 fax (513) 281-7676 url www.ucchildcare.org Copyright © 2007 University of Cincinnati