Johns Hopkins Child Care and Early Learning Center
Child Care Registration Form

To complete this registration process for your child, please fill out and then print the form from your Web browser. ALL INFORMATION ON THIS FORM IS REQUIRED BEFORE THE APPLICATION CAN BE PROCESSED.

Return the completed form to:

The Johns Hopkins Child Care and Early Learning Center
98 N. Broadway, Baltimore MD 21231
Attention: Mary Ellen Diggory, Center Director
Phone: 410-614-4111

The Registration Fee of $75.00 (siblings $65 additional) must be attached. Please make checks payable to "BHFS."

*All information needs to be filled out completely*

Child Information:
Child's name:   Date of birth:
Date you would like care to begin?   Enrolled Date (ofice use only):

Parent/Guardian Information:

Johns Hopkins Parent/Guardian Other Parent/Guardian
Name:

Name:

SSN: SSN:
Relationship: Relationship:
Home address: Home address:
Home phone: Home phone:
School/Division Employer:
Department Department
Office phone: Office phone:
Office fax: Office fax:
E-mail address: E-mail address:
Cell phone: Cell phone:

I am interested in finanial assistance and would like additional information
Yes No

Demographic Information:

Please provide information about your division or department affiliation and your employment and/or student status.
Johns Hopkins Parent / Guardian Co-Sponsor / Other Parent or Guardian

JOHNS HOPKINS UNIVERSITY

Academic Divisions:
 Bloomberg School of Public Health
Medicine
Nursing

JOHNS HOPKINS HOSPITAL / HEALTH SYSTEM
Bayview
Health System
Hospital

What color is your Hopkins badge? (i.e. yellow, if applicable)

Employment Status: (Full-time only)
Faculty
Staff
Fellow
Nurse
House Staff
Student

JOHNS HOPKINS UNIVERSITY (if applicable)

Academic Divisions:
 Bloomberg School of Public Health
Medicine
Nursing

JOHNS HOPKINS HOSPITAL / HEALTH SYSTEM
Bayview
Health System
Hospital

What color is your Hopkins badge? (i.e. yellow, if applicable)

Employment Status: (Full-time only)
Faculty
Staff
Fellow
Nurse
House Staff
Student

Schedule and Hours Desired:

MON TUES
WED THUR FRI

Parent/Guardian's Signature: ______________________________________________________
Date: ___________________________


Please enclose a check for the appropriate amount and return to: The Johns Hopkins Child Care and Early Learning Center, 98 N. Broadway, Baltimore MD 21231, Attention: Mary Ellen Diggory, Center Director, Phone: 410-614-4111.