Child’s Name*
    Date of Birth:

    Parents' Information

    Parent 1 Name*
    Parent 1 Phone:*
    Parent 1 Address:*
    What is your affiliation with UCLA?*
    Parent 2 Name*
    Parent 2 Phone:*
    Parent 2 Address:*
    Affiliated Parent is:*
    Please indicate the class you are interested in:*
    Date you would like your child to start:*
    Is Your Child Potty Trained?*
    Please indicate the days you would like your child to attend:
    Are these days flexible?*

    By submitting this application, you are stating your intention to place your child on the UPNS waiting list. Please be aware that your position on the waiting list depends on both when you applied and when your child is ready to start at UPNS. Your position on the waiting list is therefore subject to move either up or down. Your application process is not complete until UPNS receives your $50.00 (non-refundable) application fee. Your child will not be offered a space if UPNS has not received the application fee.

    Please make checks out to UPNS and mail to: UPNS 3233 S. Sepulveda Blvd. Suite 200 Los Angeles, CA 90034-4205

    UPNS accepts credit cards. We charge a 2.5% fee per transaction.

    Parent Signature:*