MILTON EARLY CHILDHOOD ALLIANCE

495 Canton Avenue

Milton, MA 02186

Phone: 617-696-2262 Fax: 617-696-2263 E-Mail: CPCMECA@AOL.com

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 2006 Federal Income Tax Returns)? $

FAMILY SIZE	50% ANNUAL INCOME	85% ANNUAL INCOME
Family of Two	$29,043	$49,372
Family of Three	$35,876	$60,990
Family of Four	$42,710	$72,607
Family of Five	$49,544	$84,224
Family of Six	$56,377	$95,841
Family of Seven	$57,659	$98,019
Family of Eight	$58,940	$100,198
Family of Nine	$60,221	$102,376

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: