Child Enrollment FormPlease complete and submit the enrollment forms below ( one form per child ) . Enrolling (check one) * Infant Toddler PreSchool Desired Enrollment Date * - Month - Day Year Date Child’s Name * First Name Last Name Date of Birth * - Month - Day Year Parents/Guardians: * Home Address * Street Address Street Address Line 2 City Please Select Massachusetts State ( Only in MA) Zip Code Please Select United States Country Preferred method of contact * Home phone Work phone Cell phone Email address Home phone * Cell phone * Work phone * Email * Languages spoken at home Please note medical history / special needs: Does your child take any medications * Yes No 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? * Yes No if Yes At Additional Comments How did you hear about Family ACCESS Early Learning Center? Check all that apply: NAEYC Referral Discussion Group Website Advertisement Google Search 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 Submit Should be Empty:
