UCA Child Study Center Waiting List Form

Thank you for your interest in the Child Study Center at UCA!
Before filling out this form please note that we follow the UCA student calendar for fall and spring semesters. We are NOT open during the summer. Our afternoon pick-up time is 3:30.
The following form will place your child on our waiting list. You will receive an email confirmation within 10 business days.
When the waiting list form is received, your child will be placed on all appropriate class waiting lists (K3 and Pre-K) according to his/her date of birth. PLEASE MAKE SURE YOUR CHILD'S DATE OF BIRTH IS CORRECT. You cannot complete this form without a date of birth. All children must turn 3 or 4 on or before August 1 of the school year to be eligible for our program. Email offers are sent in the spring for the next school year. You will be notified of which classes are available and you can decide at that time what best fits your schedule.
If your contact information changes, it is your responsibility as the parent/guardian to notify the Child Study Center. Failure to do so could result in the loss of placement on the waiting list.

Child's Name * First Last
Child's Date of Birth * / MM / DD YYYY
Child's Gender * Male Female
Parent(s)/Guardian(s) Name *
Primary Email Address- This will be used for communication with you regarding confirmation and class openings *
Secondary Email Address (not required)
Primary Phone * - (###) - ### ####
Secondary Phone (not required) - (###) - ### ####
Does your child have any identified special needs (all information is kept confidential)? * Yes No
If yes, please specify (include the diagnosis, if known, and any current therapies (OT, PT, Speech, Developmental, etc) that he/she is currently receiving
Does your child have a sibling who attended the Child Study Center? If so, please list sibling's name, year(s) at the CSC, and teacher's name (if known).
Does parent/guardian work for the University of Central Arkansas? If so, please provide name and UCA email address.