Casa Esme Enrollment Form

The Commonwealth of Massachusetts Department of Early Education and Care SG/LG/SAChildEnrollmentForm20100122

Casa Esme Enrollment Form

Child Information:

Child’s Name:Date of Birth:

Date of Admission: Age at Admission:

Home Phone: Child’s Home Address:

Primary Language:

Eye Color: Hair Color:Identifying Marks:

Sex: Height:Weight:

Parent/Guardian Information:

Parent/Guardian 1 Name:

Relationship to Child:Cell Phone Number:

Home Address: (if different from child’s)

Email Address:

Business Name and Address:

Business Phone Number: Hours at Work:

Parent/Guardian 2 Name:

Relationship to Child:Cell Phone Number:

Home Address: (if different from child’s)

Email Address:

Business Name Address:

Business Phone Number: Hours at Work:

Medical Information:

Child’s Physician and Practice:

Address:Phone Number:

Allergies/Special Diets?

Health Insurance Carrier and ID #:

Individual Health Plan for child with a chronic health condition? If yes, please attach. ( )Yes ( )No

Copies of any custody agreements, court orders, and restraining orders pertaining to the child? ( )Yes ( )No

If yes, please attach.

Special limitations or concerns?

Authorized Alternate Pick-Up Information: (People authorized to pick up child from school)

Person #1: Cell Phone:

Person #2: Cell Phone:

Emergency Contact Information (People to Contact if Parents are Not Reachable):

Contact 1 Name:

Relationship to Child:Cell Phone Number:

Home Phone: Business Phone:

Contact 2 Name:

Relationship to Child:Cell Phone Number:

Home Phone:Business Phone:

Family Information

List Names of Parents/Guardians, Grandparents, Other Relatives, Siblings and Their Ages, and Pets Who are Living at Your Child’s Home:

What would you like your child to gain from his/her childcare experience?

Off-site Permission:

I give Casa Esme permission to take my child offsite on walks in the neighborhood and to Magnolia Park.I will transport my child to and from school each day.

(Print Parent/Guardian 1 Print Name) (Print Parent/Guardian 2 Print Name)

Date: Date:

(Parent/Guardian 1 Signature):(Parent/Guardian 2 Signature):

Casa Esme Bilingual Nursery School Enrollment Form1