Child Enrollment

Enrolling*
InfantToddlerPreSchool

Desired Enrollment Date*

Name*

Child's Date of Birth*

Parents/Guardians*

Home Address*

Preferred Method of Contact
Home PhoneWork PhoneCell PhoneEmail

Home Phone*

Work Phone*

Cell Phone*

Email*

Languages Spoken at Home

Please note medical history/special needs:

Does your child take any medications*
YesNo

Health forms are required, complete with all immunization dates and lead test. No child will be allowed to attend until the appropriate health form has been received and processed. Children must have had a physical within 12 months prior to attendance.

Has your child had previous child care (family or center-based) experience?*
YesNo

If Yes at:

Additional Comments

How'd You Hear About Us?
—Please choose an option—NAEYCInternet SearchWebsiteAdvertisementSocial MediaReferralOther

Upon receipt of this completed Application Form and the $25 non-refundable application fee, your child will be waitlisted. When a space is available, a two-week security deposit will be required. Please mail your application check ( add child name in check memo) to:

FamilyAccess of Newton

Attn: Enrollment

492 Waltham Street, West Newton, MA 02465