ChildrensCenterApplication WestAllis

							Date Received:

                          MATC WEST ALLIS CHILDREN’S CENTER
                                REQUEST FOR SERVICE
Check all that apply:
         _____ Fall 2008 (2007)        _____ Spring 2008                        _____ Summer 2008

         _____ Student                 _____ Non-Student                        _____ MATC Staff/Faculty
Name of Parent/Guardian:

         Last Name                               First Name                                         Middle Initial

         Street                                                                                     Apt.#

         City                                    State                                              Zip Code

Daytime Phone #: _____________________                     Evening Phone #: __________________________


Children to enroll: (6 weeks to 13 years)

Name of Child(ren):                              Age                  Birthdate:                            Gender (M/F)
__________________________                       ______               _______________                       ___________
__________________________                       ______               _______________                       ___________
__________________________                       ______               _______________                       ___________
__________________________                       ______               _______________                       ___________

                                                         Schedule
If you are aware of the hours that you will need Childcare, please note below:
Child’s name              Monday               Tuesday              Wednesday               Thursday                 Friday




Please return the completed application to:
                                             Sharolyn Dunham
                                       MATC West Allis Children’s Center
                                            865 South 72nd Street
                                            West Allis, WI 53214
                                            dunhams@matc.edu
                                  MATC is an Affirmative Action/Equal Opportunity Institution
                            And complies with all requirements of the Americans With Disabilities Act.


EN-1.4-W (rev. 04/07)