Longwood Medical Area Child Care Center
Waiting List Application Form

Frequently Asked Questions | Application Procedures | Enrollment Form

Complete the 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:

 

Frequently Asked Questions | Application Procedures | Enrollment Form

Longwood Medical Area Child Care Center
395 Longwood Avenue     Boston, MA 02215-5328
Telephone:  617-632-2755    Fax:  617-632-2724
E-mail:  lmaccc@masco.harvard.edu

 

 
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08/16/2006

Copyright © 2000 MASCO, Inc.
375 Longwood Avenue
Boston, MA 02215
Phone: 617-632-2310
Fax: 617-632-2759