MASCO - Medical Academic and Scientific Community Organization, Inc.

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Longwood Medical Area Child Care Center
Waiting List Application Form

Complete the LMACC Waiting List Application Form below, print it out and send the application form with a
$50 non-refundable application fee. Please make your check payable to LMACCC.

Contact Information:
First Parent's/Guardian's Name:
Second Parent's/Guardian's Name:
Home Address:
City:
State:
Zip:

First Parent's/Guardian's Place of Employment:
Area Code & Telephone Number:
FAX Number:
E-mail Address:
Second Parent's/Guardian's Place of Employment:
Area Code & Telephone Number:
FAX Number:
E-mail Address:

Information on Child(ren):
	Last Name	First Name	Date of Birth (mm/dd/yy)	Sex (M/F)
1.
2.
3.

Care Requested:
Select One:	Full-time Part-time
Select Days:	Mon Tue Wed Thur Fri Flexible

Comments:


Signature:
Parent's Guardian's Signature:		By placing a check in this box you hereby state that you have placed your signature on this application form.
Date:

Longwood Medical Area Child Care Center is one of MASCO’s family of organizations.

Longwood Medical Area Child Care Center
395 Longwood Avenue, Boston, MA 02215
Telephone: 617-632-2755 Fax: 617-632-2724
Email: mdumas@masco.harvard.edu

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