Family Intake Form

Name of person completing this form:

Please choose one:

Family is new to Satellite Family has child currently enrolled in Satellite Family was enrolled in Satellite in the past

Enter information about parent/guardian:

Last Name

First Name

Email*

*Satellite uses email to communicate with families about periodic learning opportunities and upcoming events of interest to those with small children and to send our newsletter three times a year. We do not share email addresses with others. We will remove this email from our list upon request.

Phone:

Second Phone:

Street Address 1

Street Address 2

City

Family's residence is in the City of Madison proper

State

ZIP Code:

Workplace*

*We're interested in learning about workplaces that might be interested in partnering with Satellite to help their employees find and use quality family child care. We do not share family information with employers.

Enter information about a second parent/guardian or

Second Parent/Guardian

(only information different from that of first adult needs to be added)

Last Name

First Name

Email*

Phone:

Second Phone:

Workplace*

Enter information about a child enrolling in Satellite

(to enroll additional children, see "enter a second child," below)

Child's Last Name

Child's First Name

Child's Date of Birth

Child's gender:

Child's ethnicity:

Does this child have a disability? Yes No

Date child started/will start care:

Family Child Care Provider:

Care schedule:

Full-time=35 or more hours per week
Part-time=11 to 34 hours per week
Part-part-time=10 or fewer hours per week

University of Wisconsin

Is anyone in the child's immediate family affiliated with the University of Wisconsin-Madison?

Yes No (skip to next section)

UW Affiliation (please check as many as apply):
Undergraduate Student
Graduate Student
International Student
Academic Staff
Classified Staff
Post-Doc
Faculty
Visiting Professor

*Please note: UW Hospital families are tracked, but do not qualify for waived fees and do not count in the number of UW families served for reporting purposes.

UW Hospital and Clinics*
Other (please specify):

Department or degree program at UW:

Name of UW-affiliated family member:

Satellite fees (please choose one):

Family agrees to pay quarterly Satellite fees [pdf]

Satellite fees should be waived due to receiving City of Madison funding

Satellite fees should be waived due to receiving County funding

Satellite fees should be waived due to receiving CCTAP funding

Satellite fees should be waived due to income eligibility [pdf]

Parents Make a Difference:

Family is interested in being involved with Satellite

Area of Interest (check as many as apply):

Serving on the Satellite Advisory Committee

Providing technical assistance

Assisting with fundraising

Other (please specify):

Language preference

Family prefers to receive information and correspondence in Spanish

Enter information about second child below or

Second Child in Family

Full-time=35 or more hours per week
Part-time=11 to 34 hours per week
Part-part-time=10 or fewer hours per week

Enter information about third child below or

Third Child in Family

Full-time=35 or more hours per week
Part-time=11 to 34 hours per week
Part-part-time=10 or fewer hours per week

Enter information about fourth child below or

Fourth Child in Family

Full-time=35 or more hours per week
Part-time=11 to 34 hours per week
Part-part-time=10 or fewer hours per week

Any comments or questions?

For any and all children enrolled, parent or legal guardian gives permission for child's image to appear, without identification, in photos or videos, including on Satellite's website, for outreach, training, and quality improvement purposes.