Ben & Maxine Miller Child Development Laboratory School

Ben & Maxine Miller Child Development Laboratory School - Registration

Completion of the application and payment of the application fee will officially register your child on the waiting list. Choose between the online registration OR the PDF paper version. Do not submit by both methods please. Complete and submit one enrollment form per child.

Application Cover Letter and Enrollment Policy

Download the Application as a PDF form

Step 1: Contact Information

First Parent Contact Information

First Name:		Middle Initial:
Last Name:
Home Address:
City:
State:		Zip:
Home Phone #:
Work/Cell #:
E-mail:
Occupation:
Relationship to child:
Affiliation:	Purdue Faculty/Staff (Benefits eligible) Purdue Faculty/Staff (Non-benefits eligible) Purdue Full-time Student (= 8 credit hours) Purdue Part-time Student (< 8 credit hours) Community

Second Parent Contact Information

First Name:		Middle Initial:
Last Name:
Work/Cell #:
E-mail:
Occupation:
Relationship to child:
Affiliation:	Purdue Faculty/Staff (Benefits eligible) Purdue Faculty/Staff (Non-benefits eligible) Purdue Full-time Student (= 8 credit hours) Purdue Part-time Student (< 8 credit hours) Community

Step 2: Parent Information

The Ben & Maxine Miller Child Development Laboratory School offers a sliding fee scale. My family's Gross Annual Income is (based on anticipated tax return for the prior year)*:

	= $60,000
	> $60,000

*Disclosure is optional however if no data is provided the tuition rate will be based on the highest income level category

Step 3: Child's Information

Child's Name	Age	Date of Birth (mm/dd/yyyy)	Gender
			Male Female

I wish to enroll my child :
Read program descriptions and enrollment policy

in the full-day, year round program (formerly Ben and Maxine Miller Child Learning Center)

The child named on this form is currently enrolled in:

	the half-day, academic year program
	the full-day, year round program
	My child is not currently enrolled in either

Additional comments that would help us in placing this child:

The Children's Programs of Child Development & Family Studies support the inclusion of children with special needs in our programs.

Does your child have any special needs? Check all that apply.

If your child has no known special needs please select the first box.

Do any of the following apply to this child's Siblings? Please fill in all that apply.

	When:	Sibling's name:
Sibling attended the half-day (CDL) Preschool in the past?
Sibling attended the full day (MCLC) program in the past?
Sibling is currently attending half-day (CDL) Preschool?
Sibling is currently attending the full day (MCLC) program in the pas?

Step 4: Application fee

In order to cover the cost of enrolling children and maintaining our wait list, the Children's Programs require a one-time nonrefundable $20.00 per child application fee. Your child will not be placed on the waiting list until this fee has been paid. Checks should be made payable to Purdue University.

Submit application below. You must also mail or deliver your $20 application fee to:

Purdue University Children's Programs
Fowler Memorial House, RM 190
1200 West State Street
West Lafayette, IN 47906

Be sure to include your name and your child's name with this $20 payment.

I have read and understand that my child will not be placed on the waiting list until a one-time nonrefundable $20.00 fee has been paid.

Attention parents: It is the parents' responsibility to make sure we always have their current address and phone number in our files. Application update forms are sent out annually. If you do not return the completed form by the specified date, your child will be removed from the wait list. Unfortunately, we are unable to make any exceptions.

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How Are We Doing? Purdue Today

	No Known Special Needs		Emotional Disturbance
	Hearing Impairment		Down Syndrome
	Visual Impairment		Autism, Spectrum Disorders
	Orthopedic Handicaps		Learning Disability
	Speech and Language		ADHD
	Behavioral		Mentally Disabled/Developmentally Delayed
	Neurological Disorders		Other, Specify:
	Maintenance Care Diseases (Diabetes, HIV)

Vice President for Human Resources