The University of Central Florida
Parking and Transportation Services & Center for Success of Women Faculty
Expectant Mothers Parking Program
Section 1 – Customer Information
________________________________________________
____________________________________________________
Name
Department, College
________________________________________________
_________________
________________________________
Address, City, State, Zip
Phone Number
Email Address
_________________________________
_____________________________
________________________
City, State and Zip
Faculty, Staff or Student?
Employee/Student ID
Vehicle Information
______________________
___________________
___________________________________________________
Plate Number
Plate State
VIN Number (if plate number is not available)
______________________
___________________
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Vehicle Year
Vehicle Make
Vehicle Colour
Section 2 – Pregnancy Information
Type of Request (circle one):
Third Trimester Request
High Risk Request
Requested Start Date: ___________________________________________________________
Infant Due Date: ________________________________________________________________
Current Parking Lot: _____________________________________________________________
Preferred Location: _____________________________________________________________
Please fill out below for High Risk Requests
Doctor Name: ____________________________
Doctor Phone Number: __________________________________
Documentation from Doctor Provided (circle one): Yes
No
Section 3 – Expectant Mother Program Information
Faculty, staff and student permit holders in their third trimester of pregnancy may elect to reserve an expectant mother space in their
permitted lot. For convenience a spot may be selected by the expectant mother to provide a location with closer proximity to her primary
destination, within the parameters of her previously assigned lot. Should the permit holder need to make these arrangements prior to the
third trimester due to a high risk or otherwise problematic condition, medical documentation should be provided to Parking Services as soon as
it becomes available in order to provide you with this service as soon as possible. Note: This program will be run in Spring 2015 on a trial basis
to determine interest and need among faculty, staff and students.
Section 4 – Signature
I affirm all information supplied on this registration form is correct. I understand that falsification of registration material or information may
result in disciplinary action. I agree to follow the policies regarding expectant mother parking at UCF. I understand that all arrangements for
the expectant mother program will expire 7 days after the due date listed above.
___________________________________________
_____________________________________________
Signature
Date
PLEASE RETURN COMPLETED FORM TO FRAN RAGSDALE, CENTER FOR SUCCESS OF WOMEN FACULTY, FRAN.RAGSDALE@UCF.EDU.
QUESTIONS: 407‐823‐4240