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Children's Center
Prospective Families
Application for Enrollment

Application for Enrollment

There is no fee to apply
Applications may be submitted any time after a child’s 2nd birthday. Applications submitted prior to a child turning 2 years old will not be accepted.

Child's Name * Required
First Last
Birth Date * Required
MM slash DD slash YYYY
Gender * Required
- Male
- Female
Child's Home Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is your child toilet trained? * Required
- Yes
- No
- Partially
Parent/Guardian Information
Parent/Guardian 1 Name: * Required
First Last
Relationship to child * Required
Parent/Guardian 1 Home Address * Required
- Same as Child
- Other
Other
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone * Required
Email Address * Required
UIC Affiliation * Required
If you are Non-UIC or have not yet been assigned a UIN please type 'NA'
University Identification Number * Required
Name of Department/School/Employer * Required
Occupation * Required
Work Phone * Required
Work hours * Required
Parent/Guardian 2 Name * Required
First Last
Relationship to Child
Parent/Guardian 2 Home Address * Required
- Same as Child
- Other
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone * Required
Email Address * Required
UIC Affiliation * Required
University Identification Number * Required

If you are Non-UIC or have not yet been assigned a UIN please type NA
Name of Department/School/Employer * Required
Occupation * Required
Work Phone * Required
Work hours * Required
Parents' Marital Status: * Required
Members of child's home * Required
(Please list members name, age, & relationship)
Please list all language(s) spoken in your home * Required
Does your child speak English? * Required
- Yes
- No
Does your child understand English? * Required
- Yes
- No
Present child care arrangements
Previous child care arrangements
Name of company providing health insurance for your child * Required
Family's Household annual income, before taxes * Required
Please share any special concerns you may regarding your child (ie. behavioral, developmental, health, etc.)
What days and hours would you like your child to be enrolled at the Center? * Required
Desired start date * Required
MM slash DD slash YYYY
Application Policies
I understand that this application does not guarantee my child a placement at the UIC Children's Center. Enrollment is offered as spaces become available based on a family's university affiliation and the date that the application was received. * Required
- Yes
I understand that the UIC Children's Center staff will contact me at the email listed above for offers of enrollment or other important communication. I also understand that it is my responsibility to update any changes in contact information so that I may be readily contacted if a space becomes available for my child. * Required
- Yes
Phone
This field is for validation purposes and should be left unchanged.

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1919 W. Taylor St Rm 116, Chicago, IL 60612

Phone: (312) 413-5326

uicchildcenter@uic.edu

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