For Admin Use: (initial when complete)
Fee
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CHILD CARE REGISTRATION FORM
George Mason University Child Development Center
4402 University Dr. MSN 5C2, Fairfax, VA 22030-4444
(703) 993-5960 FAX 703-993-3702
Please complete the following information and submit via fax or email to cdc@gmu.edu
and submit payment of $75/child online. For details on our policies and procedures
please visit our website at: cdc.gmu.edu
CHILD’S INFORMATION
Child’s Name ____________________________ Nickname________________ Gender_____ Birth date ___________________
Child’s Home Address________________________________________________ Home Phone ___________________________
Sibling currently enrolled in CDC (please choose one) YES NO
PARENT/GUARDIAN INFORMATION
Parent’s Name _____________________________ Email address __________________________________________________
Affiliation with George Mason University: Full-time Part-time Faculty Staff Student
G# ___________________________________Mason Department____________________________________________________
Home address (if different from child’s) ________________________________________________________________________
Home Phone (if different from child’s) ________________ Cell phone ________________________________________________
Employer ________________________________ Business Phone___________________________________________________
Parent’s Name _____________________________ Email address __________________________________________________
Affiliation with George Mason University: Full-time Part-time Faculty Staff Student
G# ___________________________________Mason Department_____________________________________________________
Home address (if different from child’s) ________________________________________________________________________
Home Phone (if different from child’s) ________________ Cell phone (if applicable) _____________________________________
Employer ________________________________ Business Phone ____________________________________________________
Name of persons with legal custody of the child ___________________________________________________________________
Home address/phone (if not provided above) ______________________________________________________________________
ENROLLMENT NEEDS
We currently only offer full-time enrollment. Enrollment procedures are explained in the Parent Handbook on the Mason CDC
website. Please indicate below your scheduling needs for the child listed above. Kindly update this information via email as
necessary.
Approximate hours of care needed _________ to ________ Desired start date _________________________
Current child care: ____________________________________________________________________________
This application does not guarantee admission. When space becomes available, offers are made in the order in which the registrations
are received based on desired start date. Please contact a member of the Admin team to schedule a visit at cdc@gmu.edu.
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Signature of Parent/Guardian Date
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Signature of Parent/Guardian Date
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