Enrollment Application for both MGH Children's Center and IHP Children's Quarters
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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