Tiny Tots 
Preschool 

                   WE MAKE LEARNING FUN!

Child's Enrollment Form
Department of Early Education and Care
                                                                                                                                
PHOTO OF CHILD OR PHYSICAL DESCRIPTION:
SEX OF CHILD ________________
EYE COLOR ________HAIR COLOR _________
HEIGHT ____ WEIGHT _____SKIN COLOR _________
IDENTIFYING MARKS  ____________________

Group and School Age Child Enrollment Packet

Please fill out these forms completely. Write N/A for any question that does not apply. The forms must be returned to the program on or before the first day your child begins. Please notify the Director of any information changes throughout the year. You will be asked to review this packet and update it annually.

CHILD INFORMATION:


Child’s Name:________________ ___________ Date of Birth:_______ _____________

Age at Admission:_________________               Date of Admission:______ __________

Child’s Home Address:________________________________________________ ____

Home Phone Number:____________________  Cell Phone _______________________

Primary Language:_______________________ Identifying Marks ___________________ 


PARENT/ GUARDIAN INFORMATION:


Parent/Guardian Name: _________________________________________________________

Relationship to Child:_______________________________________________________ ____

Home Address:__________________________________________________________ ______

Reachable Phone Number:________________________________________________________

Email Address:__________________________________________________________________

Business Name:_________________________________________________________________

Business Address:__________________________Business Phone ________________________

Days/Hours at Work:_____________________________


Parent/Guardian Name: __________________________________________________________

Relationship to Child:_____________________________________________________________

Home Address:__________________________________________________________ _____

Reachable Phone Number:_________________________________________________________

Email Address:_________________________________________________________________

Business Name:_________________________________________________________________

Business Address:________________________________________________________________

Business Phone Number:__________________________________________________________

Days/Hours at Work:__________________________________________________________________

ADDITIONAL INFORMATION:

Are there any custody agreements, court orders, and restraining orders pertaining to this child?     YES / NO

(If yes, please attach copies of agreements). The program can not legally restrict either parents involvement, information sharing or pick up without a copy of any relevant legal documentation.)


Child's Physician: _________________________________________________________________

Address: ____________________________  Phone: _____________________________________

Allergies/Special Diets __________________________ Medications: _________________________

Individual Health Care Plan for chronic health conditions: ___________________________________

Special Limitations or concerns _______________________________________________________


I certify that documentation of my child's physical exam and immunizations are on file at my child's school

as required by the State of Massachusetts._____ 


SCHOOL INFORMATION: School Age ONLY

Current School:_____________________________School Address:_______________________________ School Number:_________________


______________________________________________     __________________________

PARENT/GUARDIAN SIGNATURE                                       DATE OF ADMISSION