Family, Consumer, and Human Development

EVENTS CALENDAR

25May2012

Microbial Fermentation: Development and Scale-up Training Program

This course emphasizes extensive laboratory work and…

25May2012

Women of the World Arise

Opening Reception and Commentary by the…

26May2012

Human Impacts: Natural and Man Made Disasters

This Saturday from 10-4 join us for "Human Impacts:…

29May2012

USU Student Organic Farm Stand

Come join us every Thursday for fresh organic produce,…

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Child Development Lab Application

Please fill out the information below. When this application is received, the child's name will be placed on the Child Development Laboratory Waiting Lists as indicated. We will accept 3/4 of each school group for each lab on the basis of the application date. We will accept the remaining 1/4 of each group based on other specific criteria (referrals from medical professionals, etc).

*Required

Child's Information

*First Name:

*Last Name:

*Gender:

Boy Girl

*Date Of Birth:

*Current Age (Months):

*Current Age (Years):

Family's Information

*Mother's Name:

*Father's Name:

*Address:

*City:

*State:

*Zip:

Phone:

Cell Phone:

*Email:

Mother's Business Address:

Mother's Business Phone:

Father's Business Address:

Father's Business Phone:

Emergency Contacts

Emergency Contact 1 Name:

Emergency Contact 1 Address:

Emergency Contact 1 Phone:

Emergency Contact 1 Relationship To Child:

Emergency Contact 2 Name:

Emergency Contact 2 Address:

Emergency Contact 2 Phone:

Emergency Contact 2 Relationship To Child:

Siblings

Sibling 1 Name:

Sibling 1 Age:

Sibling 2 Name:

Sibling 2 Age:

Sibling 3 Name:

Sibling 3 Age:

Sibling 4 Name:

Sibling 4 Age:

Sibling 5 Name:

Sibling 5 Age:

Sibling 6 Name:

Sibling 6 Age:

Which lab(s) would you like?

Check all age groups applicable:
(plan for the future)

Infant/Toddler (Entering Age: Newborn - 24 Months)
Two-Year-Old (Entering Age: 2 - 2 years 9 months)
Three-Year-Old (Entering age: 3 - 3 years 9 months)
Four/Five-Year-Old (4 years+, cannot be attending Kindergarten)
Summer Four/Five-Year-Old (Four years+, cannot be attending Kindergarten)