ankgoel@watmsg.waterloo.edu (anil k goel) (05/03/91)
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 __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 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. __________________________________________________________________________ PLEASE RETURN APPLICATION TO: Anil Goel Day Care Committee Graduate Student Association Grad House __________________________________________________________________________