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For Office Use Only
DATE:________ CLIENT ##:_______ SUBSIDY _______ ENTERED: _______

 

BACKUP CARE PROGRAM: JHU EMPLOYEE INFORMATION

This form may be filled out on your computer, and then printed and scanned to worklife@jhu.edu or faxed to 443-997-6609. You may also mail to WorkLife Programs at The Johns Hopkins University, 1101 East 33rd St., Suite C100, Baltimore, MD 21218.

DEMOGRAPHIC INFORMATION:

Last name: First: Middle Initial:

Date of birth: (mm/dd/yyyy) / /

CONTACT INFORMATION:

HOME:

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

WORK:

Position title:

Division: (Use the drop down arrow to find your division.)
Academic Cntrs/Support Svc Arts and Sciences Bayview Clinical Studies Engineering Health Divisions Admin Health Systems Homewood Schools Svcs Hygiene and Public Health JHU Press Medicine Nursing Peabody Professional Studies/Business Ed SAIS University Admin

Department:
Room # / Building name:

Work Phone:

By Signing this Form, I Agree to the Following:

1. I give WorkLife Programs permission to verify my employment, my salary, and dependent information.
2. I understand that it is my responsibility to report any change in my employment status, any change of address, any change of dependent care. Failure to do so may result in termination from the program.
3. I understand that providing inaccurate or false information may result in disqualification from this program and that employees who abuse the program will be reported to their divisional Human Resources office and may be subject to disciplinary action, up to and including termination.
4. I understand that changes in the Backup 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 employer sponsored dependent care assistance (ie. a Dependent Care Spending Account, the JHU Dependent Care Voucher Program, and the JHU Backup Care Program).

Signature _____________________________________ Date ____________________