Playgroup Registration

Playgroup Registration
Child’s FULL Name*
Child’s Gender:*

MaleFemale
Child’s Date of Birth (Month/Day/Year)*

MonthDayYear
Date
Child’s Home Address (Street Address and City)*
*Ethnicity (chose one):

HispanicNon-Hispanic
Race (chose all that apply)*

WhiteMiddle Easterners and North AfricansBlack or African AmericanNative Indian or Alaska NativeAsian
Is your child receiving Special Education Services?

YesNo
Is your child receiving EI Services?*

YesNo
Are there any concerns you have about your child that we should be aware of to better support you and your family?
Does your child speak any language at home other than English?*

YesNo
If yes, what language(s)?
*Does your child have allergies?

YesNo
If yes, what allergies?
Name of Adult accompanying child to playgroup*
Relationship to Child*
Phone Number*
Format: (000) 000-0000.
Email Address
example@example.com
Parent/Guardian (1)*
Date of Birth

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
Email Address*
example@example.com
Parent/Guardian (2)
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
What is the child’s household size (including the child)? Adults*
Children
In case of an emergency, Chelsea / Revere Family Network can contact or release your child to:
Full Name
Relationship
Address (Street and City)
Phone Number
Format: (000) 000-0000.
PERMISSION FOR PHOTOGRAHS AND VIDEOTAPES
Child’s Name
I give the staff of the Chelsea/Revere Family Network (which includes contracted agency staff) permission to take photographs of my child at play while he/she is attending any Chelsea Family Network activity. The photos may be used for the following purposes:
Wall Display:

YESNO
Newsletters:

YESNO
Newspaper article in local newspaper:

YESNO
Videos: (used for public relationship):

YESNO
CFN Website / Social Media

YESNO
Signature
Date

MonthDayYear
Date
GOAL PAGE
WHAT I HOPE TO GAIN FROM THE CHELSEA FAMILY NETWORK PLAYGROUP IS

One on one time with my childTalking with other parents and facilitators about parenting techniques and ideasTime for general conversation with other parentsParticipating in a structured environment with my childFacilitating a group activityOther
WHAT I HOPE MY CHILD WILL GAIN FROM THE PLAYGROUP IS:

Developmental Stimulation:Gross Motor Skills (Big Muscles)Fine Motor Skills (Hand/Eye Coordination/Small Muscles)Language DevelopmentExpressive (Saying)Receptive (Understanding)Social/ Emotional DevelopmentPlay skillsInteraction with peersSelf-care Skillso Feeding o Toileting oo Feeding o Toileting oDressingResponding to limit settingParticipating in art activitiesExposure to a structured environmentParticipating in circle timeOther goal
WHAT TYPES OF INFORMATION ARE YOU INTERESTED IN HAVING ACCESS TO?
Comments/Ideas:
Should be Empty:

Playgroup Registration

PERMISSION FOR PHOTOGRAHS AND VIDEOTAPES