Parent/Guardian 1 Name *

First Name

Last Name

Parent/Guardian 2 Name

First Name

Last Name

Child's Name

First Name

Last Name

Child's (anticipated) DOB *

MM

DD

YYYY

Classroom of Immediate Interest *

Infant & Toddler

Preschool

Home address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are you or your spouse faculty/staff at Wesleyan?

Yes

No

Approximation of childcare needs *

Check all that apply; precise needs TBD through discussion with Director

Monday

Tuesday

Wednesday

Thursday

Friday

Flexible