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| Partners/Affiliate ID#____________ |
MGH ID#____________ |
IHP Employee ID#____________ |
IHP Student ID#____________ |
Charlestown Resident |
Community |
APPLICATION SUBMISSION DATE:____________________________________________________
Child's Name _______________________________________________________________________
(Last)
(First)
(Middle Initial)
Child's Date of Birth OR Due Date: __________________ Child's Age______________ Gender________
Parent Name ______________________________________________________________________________
(Last)
(First)
(Middle Initial)
Home Address_________________________________________________________________________________________
(Street)
(Town)
(Zip)
(Home Phone # or Cell #)
Employer_________________________________
Business Phone #_____________________________
(Name
of Company)
Parent Name ______________________________________________________________________________
(Last)
(First)
(Middle Initial)
Home Address___________________________________________________________________________________________
(Street)
(Town)
(Zip)
(Home Phone # or Cell #)
Employer________________________________
Business Phone #______________________________
(Name
of Company)
Desired start date: ______________________________ Age of child then _______________________
Desired Schedule: (please circle) Full time (5 days per week) Part time (3 days per week) Part time (2 days per week)
Email address ____________________________________________________________________________
Do you have a child(ren) currently enrolled @ MGH or IHP? If yes, child & center name _______________________
Please fax or mail applications to:
Partners Child Care Services Fax: 617.726.7810
101 Merrimac Street, 3rd Floor Boston, MA 02114 Attn. Director,
Child Care Services