BrandeisUniversity MS 044

Waltham, MA02454-9110

781-736-2200//

Childcare Application

Date of applicationDate of desired enrollment

Child Applicant’s Full Name: ______Nickname: ______

If you are applying for more than one child,please fill in a second application form..

Date of birth:boygirl

This application is for School year only Summer only Both summer and school year

Please fill in the information below as appropriate for your family.

First parent’s name Gender: Male/FemaleSecond Parent’s Name Gender: Male/Female

Home Phone Home Phone

Home Address Home Address

City, State, Zip City, State, Zip

E-mail Address (Preferred) E-mail Address (Preferred)

Employer/School & Department Employer/School & Department

Occupation/Job Title Occupation/Job Title

Business Phone Business Phone

Cellular Phone Cellular Phone

With whom does the child live? ______

Are thereother children living at this child’s home? YES* NO

*If YES, please list name(s), age(s), and gender(s):

Did a child of yours ever attend Lemberg? YES* NO

*If YES, list name and approximate dates of attendance:

Are you a member of the BRANDEIS University Community (student, staff, faculty, etc)*? YES NO

(*Enrollment priority is given to employees or students of the university. Additionally, we have reserved a few spaces for Massachusetts Department of Early Education & Care referrals.)

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Has your child had previous child care experience or is your child presently in child care? YES* NO

*If yes, please write briefly about our child’s adjustment to his/her last experience:

The Center uses a sliding tuition scale. Your information booklet lists the present cost of tuition in our program. Please check the appropriate box below that most closely reflects your annualized household income. This is income from all sources (including grandparent’s contributions to day care expenses) before itemized deductions. If you’re applying at anything less than the maximum income level, appropriate documentation must be furnished upon enrollment.

___ $ 39,999 or less

___ $ 40,000 to $ 49,999

___ $ 50,000 to $ 59,999

___ $ 60,000 to $69,999

___ $ 70,000 to $ 79,999

___ $ 80,000 to $ 89,999

___ $90,000 to $119,999

___ $120,000 to $149,999

___ $150,000 or more

If you are presently eligible for or receiving subsidized day care through programs with the Commonwealth of Massachusetts Department of Early Education and Care(EEC) please check the box.

Summer applicants only:In which of the following weeks in the Summer Program would you be interested (minimum of 3)?

___ Week 1: June 23 – 27, 2014

___ Week 2: June 30 – July 3

___ Week 3: July7 – 11

___ Week 4: July 14 – 18

___ Week 5: July 21 – 25

___ Week 6: July 28– August 1

___ Week 7: August4– 8

___ Week 8: August 11– 15

The center is CLOSED August 18– 22, 2014. The school year begins August 25, 2014.

There is a $40 non-refundable application fee. This fee is waived if household income is below $40,000. Your check for the application fee should be made payable to Lemberg Children’s Center, Inc.

Please mail your Application Fee ($40) and Completed Application to:

Lemberg Children’s Center, Inc.

BrandeisUniversity

Mailstop 044

Waltham, MA02454-9110

The Lemberg Children’s Center, Inc. is a non-sectarian, not-for-profit, educational day care center which receives partial funding from the Commonwealth of Massachusetts and the U.S. Department of Education.