On-Campus Child Development Center of the Bluegrass Intent to Apply Form

Thank you for your interest in applying to place your child with the Child Development Centers of the Bluegrass' planned UK campus facility, which is scheduled to open in August 2012. UK faculty, staff and students who complete the intent to apply form below will receive priority consideration for placement, in the order the forms are submitted. Parents applying through this priority process will receive notice of their application status no later than May 1, 2012.

Child(ren) Information

* Child #1's First Name

* Child #1's Last Name

* Child #1's Gender

* Child #1's Birth Date, including year (example: 12/21/2007)

* I am requesting enrollment for my child as

Typically Developing

Known Developmental Delay

Suspected Developmental Delay

Child #2's First Name

Child #2's Last Name

Child #2's Gender

Child #2's Birth Date, including year (example: 12/21/2007)

I am requesting enrollment for my child as

Typically Developing

Known Developmental Delay

Suspected Developmental Delay

Child #3's First Name

Child #3's Last Name

Child #3's Gender

Child #3's Birth Date, including year (example: 12/21/2007)

I am requesting enrollment for my child as

Typically Developing

Known Developmental Delay

Suspected Developmental Delay

* Child(ren) resides with

* Child(ren) is custody of

UK-affiliated (Faculty, Staff or Student) Parent/Guardian Information

Please provide information about you and your affiliation with the University of Kentucky.

* Applicant's First Name

* Applicant's Last Name

* Applicant's UK Job Title

* Applicant's UK Department

* Applicant's UK Email Address

* Applicant's UK Phone Number

* Applicant's Home Phone Number

* Applicant's Cell Phone Number

* Applicant's Marital Status

Single

Separated

Married

Divorced

* Applicant's Relationship to Child

Mother

Father

Guardian

Address Information

Home Street Address

Home City

Home County

Home State

Home Zip Code

Additional Information

If you have additional comments or questions, please contact CDCB’s Enrollment Director, Heather Henry, at 859-278-0549. You may also add any additional comments or questions below.

* Indicates Response Required