New Enrollment Forms - Family ACCESS Early Learning Center

Enrolling (check one) *

Infant Toddler PreSchool

Desired Enrollment Date *

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	State ( Only in MA)
Zip Code	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:

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

New Child Application