Date of Application __________________ Received by ________________________
Date Received ______________________
East Tennessee State University
Little Buccaneers Student Child Care Center
Application Information
Child’s Name ________________________ Social Security # __________________
Birth Date _________________________Age at entrance into the program_________
Parent
Information
Mother_________________________________________________________________
HomeAddress___________________________________________________________
______________________________________________________________________
(city, state, zip code)_______________________________________________________
Home Phone (________)________________ Cell (________)______________________
Social Security# ___________________ Email _________________________________
Father__________________________________________________________________
Home Address___________________________________________________________
_______________________________________________________________________
(city, state, zip code)_______________________________________________________
Home Phone (________)________________ Cell (________)____________________
Social Security# ___________________ Email ______________________________
Please list any placements for Federal Work Study, APS Scholarship, or Graduate
Assistantship.
Placement: ______________________ Contact ______________ Phone #_____________
Pertinent information we should know about your child:
|