Child and Family Center at Shippensburg University

A Project of the Shippensburg University Foundation

Child Care Interest Form

Date of Application ___________________

Child’s Name __________________________________________________________________

                                    (Last)                                       (First)                           (Middle Initial)

Male ____  Female ____         Child’s Date of Birth _______________         

Home Address ___________________________________              ________________________

                                                                                                            Home Telephone Number

                        ____________________________________

Parent/Guardian Name __________________________________    ________________________

Work Telephone Number

Parent/Guardian Name __________________________________    ________________________

                                                                                                            Work Telephone Number

Are you or your co-parent a student, staff member, faculty member or administrator of Shippensburg University ?    (Please circle)

How did you hear about our program? _____________________________________________

Child care is available on a full-day or part-day basis.  Children enrolled for 5 or more hours per day are considered full-time.  Children enrolled less than 5 hours per day(either AM or PM) are considered part-time.

Please indicate days and beginning and ending times that you desire child care service:

Please indicate the date you wish to have child care services begin:                                           

A $45 Non-refundable registration fee per family, payable to The Shippensburg University Foundation, must accompany this interest form (application and payment of fee does not guarantee enrollment in the program).  Please mail interest form and payment to:

Child + Family Center

1871 Old Main Dr .

Shippensburg , PA    17257