CCSS Interest Form

Child Care Services for Students

Students, or potential students, who are interested in child care for their children when they are attending
class at C.O.D. may submit their information to the Director of Student Activities. Sufficient interest will need
to be documented before any discussions are opened concerning revitalizing this service.

Student Information
Student's (parent) Name:
Student's Address:
City:
State:
Zip Code:
Student's Phone Number:
Student's E-mail Address:
Currently enrolled at C.O.D.	Plan to be enrolled at C.O.D.	Part-time faculty member at C.O.D.
I plan to be a student at C.O.D. until: Program of study (major) at C.O.D.:
Please indicate the class schedule you are planning for fall 2008 with days of week and class times Do you plan to enroll for spring 2009? yes no

Child Information
First Child:	Age as of 9/1/08
Second Child (if applicable):	Age as of 9/1/08
I learned about the Child Care for Students:
In the College catalog	In a local newspaper article
Browsing the college's web site	From another student
From a neighbor or friend	From an advisor or teacher at College of DuPage
Other, please specify (50 characters):
Impact of cancellation of Child Care for Students:
It will take me longer to complete my certificate/degree at C.O.D.
I have had to find other child care placement for my child Please describe your current child care arrangements while you attend C.O.D.
I will not be able to take classes at C.O.D.