PCC application

Enrollment Application

1.	Desired date of enrollment
	Application date

2.	Please indicate your choice of program:	Summer Full year program Fall/Winter program only

3.	Please indicate your choice of days:	5 days 4 days 3 days 2 days

4	Please indicate which days of the week you would be sending your child to daycare.	Monday Tuesday Wednesday Thursday Friday

5	Child's full name
	Sex	Male Female
	Present Age
	Birth Date

6.	Address
	Home Telephone

7.	Parent's Full Name Email Address
	Sex	Male Female
	Home Address
	Home Telephone
	Work Telephone Alt./Cell Phone
	Parent's Occupation
	Company Name
	Company Address
	University of Pennsylvania affiliation:	Yes No
	If yes:	Employee Student Full time Part time

8.	Parent's Full Name Email Address
	Sex	Male Female
	Home Address
	Home Telephone
	Work Telephone Alt./Cell Phone
	Parent's Occupation
	Company Name
	Company Address
	University of Pennsylvania affiliation:	Yes No
	If yes:	Employee Student Full time Part time

9.	Previous school / nursery / childcare attendance?	Yes No
	If yes, please explain briefly.

10.	General Health	Excellent Good Fair Poor
	Please explain briefly.
	Does your child have any special physical, medical or dietary needs? Allergies? Please explain.

11.	Would you like us to mail you information on the limited fee assistance or loan programs available to full-time Penn students and employees?	Yes No

12.	Time child will arrive at Center
	Time child will depart

The following information is voluntary:

13. Child's ethnicity: African-American
Asian
Asian/Indian
Caucasian
Hispanic
Middle Eastern
Other

14. How did you hear about the Penn Children's Center?

Please print this form and mail it with your non-refundable application fee of $25.00 to:

Penn Children's Center
3160 Chestnut Street, Suite 100
Philadelphia, Pennsylvania 19104-6282

Your child will not be put on the waiting list until your application fee is received.

We do ask that you contact the center to verify that your application has been received. Thank you for your help!

The following information is voluntary:
13.	Child's ethnicity:	African-American Asian Asian/Indian Caucasian	Hispanic Middle Eastern Other

14.	How did you hear about the Penn Children's Center?