🚀 go-pugleaf

NAME:_______________________________________________________ SEX*:  M   F

CAMPUS MAILING ADDRESS: DEPARTMENT ______________________BUILDING_________

UW EXTENSION:___________HOME PHONE #:__________________STUDENT #__________

PROGRAM: M.A.           Ph.D.               TERM IN PROGRESS:_____________

REGISTRATION STATUS:      FULL-TIME                  PART-TIME

FINANCIAL SUPPORT FOR SPRING TERM (specify term total in Canadian dollars):

               T.A.                $__________________

               R.A.                $__________________

               SCHOLARSHIPS:       $__________________

               OSAP:               $__________________

               OTHER:              $__________________

               _______________________________________
               TOTAL SUPPORT
               FOR SPRING TERM     $__________________

ARE YOU A SINGLE PARENT?       YES       NO

NUMBER OF CHILDREN: _______________

CHILD'S NAME     AGE    CENTRE &    FULL/PART  COST/MONTH   WAITING LIST?
________________________PHONE #_____TIME CARE              IF YES,POSITION

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HAVE YOU APPLIED OR DO YOU PLAN TO APPLY FOR DAY CARE BURSARIES FROM YOUR

FACULTY?      YES         NO

IF YES, WHICH FACULTY?

HAVE YOU APPLIED FOR A REGIONAL DAY CARE SUBSIDY?      YES         NO

IF YES, HOW MUCH ARE YOU RECEIVING?


     DON'T FORGET TO INCLUDE A PHOTOCOPY OF A RECEIPT OR LETTER FROM THE
     DAY CARE CENTRE.  INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED!


*NOTE: You must be female to qualify for a bursary.


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PLEASE RETURN APPLICATION TO:

		Anil Goel
		Day Care Committee
		Graduate Student Association
		Grad House
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