Child Care Subsidy Application Form - Campus Life

Student ID Number:

Applicant:

New Applicant

Previous Applicant

Please check ONE

Applicant First Name:

Applicant Middle Initial:

Applicant Last Name:

Applicant Address:

City:

State:

Zip Code:

Date of Birth:

(MM/DD/YYYY e.g., 01/01/2010)

UW-Superior E-mail Address:

Telephone Number:

Are you planning to graduate this current academic year?:

Yes

No

If yes, indicate semester of graduation:

Fall

Spring

Summer

(check one)

Check Which Child Care Center Your Child(ren) are Enrolled in:

New Horizons (Sundquist)

Noah's Ark

Superior Children's Center

YMCA Discovery Program (Hawkes)

Please indicate the number of days per week child(ren) are in the center:

Check all the terms you will be enrolled at UW-Superior and are applying for Subsidy Funds:

Fall

Spring

Summer

Family Information

Marital status:

Single

Married

Divorced/Separated

Spouse is a student at UW-Superior:

Yes

No

If yes, spouse student ID#:

Name of spouse:

Last, First MI

1 Name and DOB child:

2 Name and DOB child:

3 Name and DOB child:

4 Name and DOB child:

Campus Email:

Enter your campus email address in place of your signature to acknowledge the above statements

University of Wisconsin-Superior: College degrees, bachelors, masters

Wisconsin's Public Liberal Arts College

Child Care Subsidy Application Form - Campus Life