First Time Reservation Request Form Parent's Full Name(required) Email(required) Phone(required) Child(ren)'s Name(s) **PLEASE LIST INDIVIDUALLY**(required) Child(ren)'s Date(s) of Birth(required) Date of Reservation Requested(required) Time of Reservation Requested (Begin AND End)(required) Will you be using any outside funding for this reservation (ex. Kids Kare, Shares, SMPH DISCOUNT)?(required) Yes No Are you affiliated with University of Wisconsin-- Madison? **It is not required that you have a UW Madison affiliation to use the center**(required) Not Affiliated UW-Madison student UW-Madison University Staff UW-Madison Academic Staff UW-Madison Faculty UW-Madison Fellow/Scholar/Post-Doc UW-Hospital and Clinics If you have a UW Madison affiliation, please enter your department. ASK ABOUT OUR SCHOOL OF MEDICINE & PUBLIC HEALTH DISCOUNT. Does your child have any special needs or allergies we should be aware of?(required) I have read and understand the Little Chicks policy and procedures. (required) Submit Δ Like this:Like Loading...
