Infant/Toddler Registration: 2015-2016
(6 weeks to 2 years)
Helen R. Godfrey – University Child Learning and Care Center
910 Fremont Street, Stevens Point, WI 54481
Child’s Name
Home Address
City/State/Zip
Home Phone
Application Date
Birth Date
Age
Sex
Parent’s Cell Phone
Parent’s Name (Guardian)
E-Mail
Status: check one
UWSP Student
Faculty/Staff
Employee ID #
# of credits
Alumni
Other
Driver’s License #
Social Security #
Parent’s Name (Guardian)
E-Mail
Status: check one
Student – Full time
Faculty/Staff
Employee ID #
Student – Part time
Alumni
Other
*Driver’s License #
*Social Security #
*All personal confidential information is retained in a highly secured location with very limited access and not further shared
Payment – Check one
Paid in full by self
Other, please explain
County Assistance
Delinquent Payments: Individuals not paying on time will be billed an additional $10.00 late fee. A bill
is considered late if it is left unpaid after a 10-day period from the billing date.
Child’s schedule for each day: Please record your Child’s Schedule for each day they will attend.
Please indicate what hours your child will attend between 7:30AM and 5:30PM. The rate is the same
regardless of hours used. (Please note: fulltime care is the only option. UCLCC is currently not
accepting part-time infants/ toddlers.)
Day
Monday
Tuesday
Wednesday
Thursday
Friday
Write in Estimated Arrival & Departure Times
Please check appropriate time block(s) needed:
Full Calendar Yr
Full Academic Yr ’15-‘16
May 18, 2015 to May 20, 2016
May Interim ‘15
Summer ‘15
August Interim ‘15
Semester I ’15-‘16
Winterim ‘16
Semester II ’15-‘16
May 18, 2015 - June 12, 2015
June 15, 2014 - August 7, 2015
August 10, 2015- August 28, 2015
Sept. 2, 2015 – Dec. 22, 2015
January 4, 2016- January 20, 2016
Jan. 25, 2016 – May 20, 2016
Sept. 2, 2015 – May 20, 2016
Full Time Rates Effective June 1, 2015:
Registration Fees:
Initial Student
Initial Non-Student
Continuing Student
Continuing Non-Student
Student Rate
Non-Student Rate
$50.00
$75.00
$20.00 per semester
$25.00 per semester
Full Time
175.00
225.00
May Interim, Summer, & August Interim ONLY:
Student Rate
Non-Student Rate
Two Full Days
105.00
N/A
Three Full Days
130.00
N/A
Full Week
175.00
225.00
*These rates will also be used for any drop-in care that we are able to accommodate.
Family Discount: Additional children from the same family receive 10% off the lowest rate on
the 2nd child and each subsequent one thereafter.
Priority will be given to the following in order listed upon avalibility:
1. Students
2. Faculty/Staff
3. Community
Permission: Check One
Yes
No
I give permission for my child to participate in all walking trips
originating at UCLCC to points of interest on or near campus.
I give permission for students enrolled in UWSP classes to do volunteer
work with my child under supervision of UCLCC staff.
Insurance Information: Is participant covered by family medical/hospital insurance? □ Yes □ No
Carrier/Plan Name _____________________________Group/Policy # ____________________
Name of insured ____________________Relationship to participant _____________________
By signing below, you are agreeing to all policies in the Parent Handbook, our fee schedule,
and accepting responsibility for payment of your child’s scheduled hours (unless covered by
another agency). If you do not understand a policy or procedure, please write it below and
the director will contact you to further discuss it.
_____________________________________________
Parent(s)/Guardian(s)
____________________
Date