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JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE: BACKUP CARE PROGRAM
RESIDENT INFORMATION

This form may be filled out on your computer, printed and mailed or hand carried to the Registrar's Office, Broadway Research Building, Suite 147, 733 N. Broadway, Baltimore, MD 21205.

DEMOGRAPHIC INFORMATION:

Last name: First: Middle Initial:

CONTACT INFORMATION:

HOME:

Street: Apt #:
City: State: Zip Code:
E-mail:
Home Phone: Fax: Pager:
Cell Phone:

WORK:

Position title: Resident Staff

Division: (check one)
Johns Hopkins Hospital (JHH)
Johns Hopkins Bayview Medical Center (JHBMC)

Department:
Work Phone:

By Signing this Form, I Agree to the Following:

1. I give the Registrar's Office and WorkLife Programs permission to verify my status, my salary, and dependent information.
2. I understand that it is my responsibility to report any change in my status, any change of address, any change in number of dependents to the Registrar's Office, 410-614-3301.
3. I understand that providing inaccurate information may result in disqualification from this program.
4. I understand that changes in the Back-up Care Program may be necessary to ensure that funds are available throughout the year.
5. I understand that the provider is screened by Parents in a Pinch or a licensed agency, but acceptance of any dependent care provider is my exclusive responsibility.
6. I understand that 10 placements is the maximum allowed each year and that one placement can not exceed 12 hours of dependent care.
7. I understand that $5,000 is the combined total allowed by the Internal Revenue Service (IRS) per family, per calendar year, for dependent care assistance from the Dependent Care Reimbursement Account, the Dependent Care Scholarship Program at the JH Early Learning and Child Care Center, and the JHU Back-up Care Program.

Signature _____________________________________ Date ______________________