BrandeisUniversity MS 044
Waltham, MA 02454
// 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. Our website 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 26 – 30, 2017
___ Week 2: July 3 – 7 (closed July 4th)
___ Week 3: July10 – 14
___ Week 4: July 17 – 21
___ Week 5: July 24 – 28
___ Week 6: July 31– August 4
___ Week 7: August7– 11
___ Week 8: August 14– 18
The center is CLOSED August 21– 25, 2017. The school year begins August 28, 2017.
Will you be in need of part-time care? YES* NO
*If YES, please select which consecutive days
___ 2 days: Monday/Tuesday ___ 3 days: Monday/Tuesday/Wednesday
___ 2 days: Tuesday/Wednesday ___ 3 days: Tuesday/Wednesday/Thursday
___ 2 days: Wednesday/Thursday ___ 3 days: Wednesday/Thursday/Friday
___ 2 days: Thursday/Friday ____Flexible:______
How did you find out about us? ______
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.