MILTON EARLY CHILDHOOD ALLIANCE

495 Canton Avenue

Milton, MA 02186

Phone: 617-696-2262 Fax: 617-696-2263 E-Mail: cpcmecasld@verizon.net

Tuition Assistance Intake Form

Date this form was completed:

Person who completed form: G Parent G Guardian

Does Parent(s) have special needs/disability? If yes, describe:

Daytime phone number: Milton phone number:

Street address:

Child’s First name: Child’s Last Name: G Male G Female

Child’s date of birth: Does child have special needs or an IEP?

Is child currently attending a child care program? G Yes G No If yes, where, days per week and hours per

day? Otherwise, schedule needed:

QUALIFICATIONS:

Are parent(s) Milton resident(s)? G Yes G No

Are Parent(s) working more than 20 hours per week? G Yes G No

Is child 2.9 yrs. to Kindergarten eligible? G Yes G No

Where does adjusted gross family income fall within the following chart

(per line 37 on 2007 Federal Income Tax Returns)? $

FAMILY SIZE	50% ANNUAL INCOME	85% ANNUAL INCOME
Family of Two	$30,378	$51,643
Family of Three	$37,526	$63,794
Family of Four	$44,674	$75,945
Family of Five	$51,822	$88,097
Family of Six	$58,970	$100,248
Family of Seven	$60,310	$102,526
Family of Eight	$61,650	$104,804
Family of Nine	$62,990	$107,083

FAMILY INFORMATION:

What is total family size? (only include all those listed as deductions on income tax return).

Please list all dependents:

Parent’s name: G Male G Female Date of Birth:
Parent’s name: G Male G Female Date of Birth:
Guardian’s name: G Male G Female Date of Birth:
Sibling’s name: G Male G Female Date of Birth:
Sibling’s name: G Male G Female Date of Birth:
Sibling’s name: G Male G Female Date of Birth:
Sibling’s name: G Male G Female Date of Birth:
Sibling’s name: G Male G Female Date of Birth:

Total hours per week Mother works? Total hours per week Father works?

Primary language spoken in home: Secondary language spoken in home:

Notes: