Child Enrollment Form
By The Commonwealth of Massachusetts Department of Early Education and Care
Childs Name
Date of Birth
/
Month
/
Day
Year
Date
Age at Admission
Date of Admission
/
Month
/
Day
Year
Date
Childs Home Address
Home Phone Number
Primary Language
Identifying Marks
Eye Color
Hair Color
Skin Color
Sex
Height
Weight
Parent/Guardian Name 1
Relationship to Child
Home Address
Reachable Phone Number
Email Address
example@example.com
Business Name
Business Address
Business Phone Number
Hours at Work
Parent/Guardian Name 2
Relationship to Child
Home Address
Reachable Phone Number
Email Address
example@example.com
Business Name
Business Address
Business Phone Number
Hours at Work
Childs Physician
Address
Phone Number
Allergies/Special Diets
Individual Health Plan for child with a chronic health condition? If yes please attach below:
Please Select
Yes
No
Attach any Individual Health Plans for your child.
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Do you have any custody agreements, court orders, and restraining orders pertaining to the child? If yes please attach below:
Please Select
Yes
No
Attach any custody agreements, court orders, and restraining orders pertaining to the child for your child.
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Special limitations or concerns? If yes, explain below:
Please Select
Yes
No
Please explain any special limitations or concerns. If there are none, please type NA.
Current School
School Address
School Phone Number
Please upload your child's most recent physical from within the past year.
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Please upload your child's immunization record or a letter explaining any exemption.
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Please upload a copy of your child's lead screening results.
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I certify that documentation of physical examination and immunizations in accordance with public school health requirements and lead poisoning screening in accordance with public health requirements are on file at my child's school. Parent/Guardian initials:
I have filled this form out to the best of my knowledge. Parent/Guardian Signature:
Date
/
Month
/
Day
Year
Date
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Should be Empty: