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|
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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)
Child's Date of Birth / Due Date: __________________ Child's Age______________ Gender________
Parent Name __________________________________________________________________________
(Last)
(First)
(Middle)
Address____________________________________________
_____________________________
(Street)
(Town)
(Zip)
(Phone #)
Employer____________________________ Business
Phone #__________________________
(Name
of Company)
Parent Name _______________________________________________________________________
(Last)
(First) (Middle)
Address____________________________________________
_____________________________
(Street)
(Town)
(Zip)
(Phone #)
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