University of Maine Children's Center
113 College Avenue
Orono, ME  04473

Telephone/Fax: (207) 581-4076

 

PRELIMINARY CHILD CARE APPLICATION
 

(FOR OFFICE USE ONLY)
 

 

 

Databased by ___________
 

Child's Name: _________________________________________________________
Birth Date: ____________________________________Male:______ Female:______
Parent Name: ________________________________________________________
Parent Name: ________________________________________________________
Mailing Address: ______________________________________________________
Home Telephone Number: _______________________________________________
Parent Contact Telephone Number/s: ______________________________________
_____________________________________________________________________

Parent's University of Maine status:
___currently UM (Orono) student ___future UM (Orono) student (state date:_______)
___full-time undergraduate student (12 credits or more per semester)
___part-time undergraduate student (less than 12 credits per semester)
___currently UM (Orono) employee
       ___full-time regular employee
       ___part-time regular employee
       ___temporary employee
___no University of Maine (Orono) affiliation

Parent's University of Maine status:
___currently UM (Orono) student ___future UM (Orono) student (state date:_______)
___full-time undergraduate student (12 credits or more per semester)
___part-time undergraduate student (less than 12 credits per semester)
___currently UM (Orono) employee
      ___full-time regular employee
      ___part-time regular employee
      ___temporary employee
___no University of Maine (Orono) affiliation