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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