Date Received:____ - Integrated Health Care System



Date Received:_____________

Check Date:_______________

Class:____________________

APPLICATION

McLean Affiliation: (Please check one)

____1. Sibling of currently enrolled child

____2. FT or PT McLean Hospital employee

____3. Attending

____4. No McLean Hospital affiliation

Child's Name ______________________________________ Date of Birth_____________________________________

Address __________________________________________ Telephone ______________________________________

__________________________________________

Guardian #1 _______________________________________ Guardian #2 _____________________________________

Employer__________________________________________ Employer _______________________________________

Business Phone ____________________________________ Business Phone _________________________________

Email address ______________________________ _______________________________________

Desired Start Date ________________________

Please check which days you will need care:

_________ Monday _________ Tuesday _________ Wednesday _________ Thursday _________ Friday

Please give us the approximate times you are looking for: _________AM TO ________PM

We will attempt to accommodate the schedule you request but can not guarantee these hours will be available. Please keep in mind that the 2 and 3 day options are offered on a space available basis as schedules must match in order to balance center enrollment. The center is open from 6:45am to 5:30pm. Please note that submission of an application does not guarantee enrollment at the center. Spaces are assigned as they become available.

The application fee of $50 is non-refundable. Please enclose a check made payable to the McLean Child Care Center and mail to:

Director

McLean Child Care Center, Mailstop 118

115 Mill Street

Belmont, MA 02178

McLean Child Care Center does not discriminate in providing services to children and their families on the basis of race, sex, religion, cultural heritage, political beliefs, marital status, disability or ethnic origin.

McLean Child Care Center is NOT a “peanut free” (or any other allergy) environment.

********************************************************************************************************************************************For Office Use Only:

Space available: __________ Contacted: __________ __________ __________

Packet Sent: __________ Deposit Amount: _______________ Deposit Due: _______________

Deposit Received: __________ Tuition Contract Sent: __________ Visit Dates:__________ _________ ___________

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