Greater Quincy Child Care Center
Enrollment Application
Parent's Name: _________________________________________________
Home Address: _________________________________________________
Home Phone: (____)____________________
E-Mail Address: ____________________________________
Father's Employer: ______________________________________________
Business Address: __________________________________________
Business Phone: (____)______________________________________
Mother's Employer: _____________________________________________
Business Address: _________________________________________
Business Phone: (____)______________________________________
Child's Full Name: ____________________ Sex: _____ Age: ______ D.O.B. _____
Child's Full Name: ____________________ Sex: _____ Age: ______ D.O.B. _____
Desired Enrollment Date: ________________________________________________
Number of Days per Week: _______________________________________________
____________________________
Parent's Signature
******************************************************************************************************************
For Center Use:
Date Application Received: _____________________________
Enrolled in the Program: ________________________________
Please mail to: Greater Quincy Child Care Center
859 Willard Street
Suite 100
Quincy, MA 02169
Or Fax to: 617-773-8704