Enrollment Application for Partners Children’s Center at Assembly Row

Please note: Applications for to-be-born or to-be-adopted children may only be submitted after a family is confirmed pregnant or has formally entered into an adoption agreement.

APPLICATION SUBMISSION DATE: 9/26/2018
Child's Name
Last:
First:
Middle Initial:
Child's Date of Birth OR Due Date, Please ensure that Month, Date and Year are accurate:
Gender

FOR 2-PARENT FAMILIES, PLEASE FULLY COMPLETE INFORMATION FOR BOTH PARENTS

Parent 1 Name
Parent 2 Name
Last:
First:
Middle Initial:
Last:
First:
Middle Initial:

Home Address Parent 1
Home Address Parent 2
Street:
Town:
State:
Zip:
Home Phone#: (format: xxx-xxx-xxxx)
Cell Phone#: (format: xxx-xxx-xxxx)
Street:
Town:
State:
Zip:
Home Phone#: (format: xxx-xxx-xxxx)
Cell Phone#: (format: xxx-xxx-xxxx)

Check all that apply:





Submit Application?
Employer Parent 1
Employer Parent 2
Name of Employer:

Affiliation, please make choices: BWH, MGH, PHS (Partners Corporate), IHP, Partners Member Hospital, Charlestown Resident, Community:

Employee ID#, typically found on the back of employee photo ID badge (format = 9 numbers):

Work Phone #: (format: xxx-xxx-xxxx)
Work Email Address:
Home Email Address:
Name of Employer:

Affiliation, please make choices: BWH, MGH, PHS (Partners Corporate), IHP, Partners Member Hospital, Charlestown Resident, Community:

Employee ID#, typically found on the back of employee photo ID badge (format = 9 numbers):

Work Phone #: (format: xxx-xxx-xxxx)
Work Email Address:
Home Email Address:

Desired start date, please ensure that Month, Date and Year are accurate:
Age of child at desired start date
Desired Schedule:
(Please select) Full time (5 days per week) Part time (3 days per week) Part time (2 days per week)
If Part Time, Please indicate desired days of the week.
Comments. 500 characters maximum.

Families who have submitted a waitlist application will be contacted in Spring 2018 with an update on the status of their application.

Applications will remain active on the waiting list for one year after desired start date, after which they will be removed. For example, if desired start date is September 4th, 2018, the application will remain active on the waiting list until September 4th, 2019, after which it will be removed.

Applicants declining an offer of enrollment will be removed from the waiting list. Applicants wishing to be placed on the waiting list again after their application has been removed (either due to expiry or declining an offer of enrollment) must submit a new application.

Print Form Before Submitting

Please review your application carefully before submitting to ensure accuracy, paying particular attention to dates entered. Thank you.
  • One application must be submitted for each child you wish to place on the waitlist; if you are submitting more than one application, the electronic submission system requires that you wait at least 10 minutes between submissions to ensure placement on the list for each application.

  • After clicking ‘Submit Application’ you will be taken to a confirmation screen and provided a confirmation number for this submission; if you do not receive a confirmation number, you have not been placed on the waitlist, you must resubmit, thank you.

  • The Confirmation Number that you receive on the next screen is the only confirmation you will receive; you will not receive a separate email confirmation or communication regarding this application.

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