Enrollment Application for MGH Children's Center and IHP Children's Quarters
 |
 |
| 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
101
Merrimac Street, 3rd Floor
Boston,
MA 02114 Attn. Director, Child Care Services
Fax:
617-726-7810