Child's First Name    Child's Last Name 

Child's Date of Birth:                         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?

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.

Monday   AM  PM
Tuesday   AM  PM
Wednesday   AM  PM
Thursday   AM  PM
Friday   AM  PM

Are these days flexible?  Yes   No

Is Your Child Potty Trained?  Yes   No

Date you would like your child to start:       

By submitting this application, you are stating your intention to place your child on the UPNS waiting list.  Please be aware that your position on the waiting list depends on both when you applied and when your child is ready to start at UPNS.  Your position on the waiting list is therefore subject to move either up or down.  Your application process is not complete until UPNS receives your $50.00 (non-refundable) application fee.  Your child will not be offered a space if UPNS has not received the application fee.

Parent Signature

Please make checks out to UPNS and mail to:

3233 S. Sepulveda Blvd. Suite 200
Los Angeles, CA 90034-4205

We are sorry, but UPNS does not accept credit cards at this time.


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