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* 1. Legal Guardian or Parent Name

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* 2. Email

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* 3. Ball State Affiliation

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* 4. Child 1 Full Name

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* 5. Child 1 Birth Date

Date

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* 6. Child 2 Full Name

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* 7. Child 2 Birth Date

Date

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* 8. Child 3 Full Name

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* 9. Child 3 Birth Date

Date

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* 10. Child 4 Full Name

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* 11. Child 4 Birth Date

Date

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* 12. Are all of the children listed above your legal dependents? The affiliated rate is only applicable to legal dependents of Ball State affiliates.  If no, then please list which children are not your legal dependents.

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