Child's First Name    Child's Last Name 

Child's Date of Birth:    2003 2004 2005 2006 2007 2008 2009      January February March April May June July August September October November December      1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31            Male    Female

Father's Name       Mother's Name 

Street Address 

City    State  Zip 

Home Phone ()  

Mother's Work Phone ()  

Father's work Phone ()  

Email Address 1  Mother Father

Email Address 2  Mother Father

What is your affiliation with UCLA?
Student
Post-Doc
Faculty
Staff
Alumni
None

Affiliated parent is:  Mother Father Both

Please Indicate the Class You are Interested In:
Kittens (Ages 2-3)
Monkeys ( Ages 3-4)
Dolphins (Ages 4-5)
Koalas (Ages 3-5) (afternoons only)

Please indicate the days you would like your child to attend:
Please note that only children enrolled in the Koala class can attend afternoons only.  Children enrolled in all other classes may attend morning only, or morning and afternoon.   A minimum of three boxes must be checked.

Are these days flexible?  Yes   No

Is Your Child Potty Trained?  Yes   No

Date you would like your child to start:   January February March April May June July August September October November December      2009 2010 2011 2012 2013