Indicate your first choice center by selecting "1" from a drop box below. If you also wish to indicate a second or third center of interest please select "Y" in the corresponding drop box. If you are not interested in a specific center, select "N" in the corresponding drop box. Families will be notified of openings at your first choice center and any centers marked with a "Y." You will NOT be notified of any openings at the center(s) you have marked with an "N."

-Select- 1 Yes No	-Select- 1 Yes No	-Select- 1 Yes No	-Select- 1 Yes No
Marilyn Reed Lucia Center three-months to 23 months 610 Parnassus Ave. t: 415-476-1616 f: 415-476-6787 yolanda.marquez@ucsf.edu	Kirkham Street Center 24 months to five years 10 Kirkham St. t: 415-476-1616 f: 415-476-6787 yolanda.marquez@ucsf.edu	Mission Bay Center three-months to five years 1555 6th St. t: 415-255-7954 f: 415-255-7353 missionbay@brighthorizons.com	Laurel Heights Center three-months to five years 3333 California St. t: 415-775-2111 f: 415-775-2122 jcohn@marindayschools.org

Please list all other adults and children that live with the child and indicate their relationship to the child

Please state any significant conditions (health, social, emotional, allergies) that we should know about your child

How did you hear about University Child Care Centers?

Preferred Starting Date

22

Number of days per week:  5 (M-F)  2 (T, TH)  3 (M, W, F)

Name of Parent/Guardian 1 Date

I certify that the above information is correct.

Please select a center as your first choice to see payment information.