Registration Form 4-5 year olds
Fall 2016
Please fill in the information for all adults and children who will attend the playgroup together. You may use the Translate button on the bottom of this website to translate this form. You may print this page or view here to print the form.
Parent/Caregiver Name: _________________________________________________________________________
My child(ren) will be attending the playgroup with: ____________________________________________________
Relationship to Child(ren) (please check one): ___ Mother ___ Father ___ Grandparent ___Other Relative
___Child Care Provider
Address __________________________________________________ Norwood, MA 02062
Phone ______________________ Email ______________________________________________________
Please list ALL children you will be bringing to the group. If you do not have enough space, please write all the children on the back of this form and note that below. Thank you! Children must be 48 mo. (4 yrs.) to 60 mo. (5 yrs.)
Child’s Full Name ____________________________________ Date of Birth ______________________
Child’s Full Name ____________________________________ Date of Birth ______________________
Emergency Contact:_______________________________ Telephone Number: ________________________________
Do any of the children have special needs or allergies that we should know about? YES NO
If yes, please describe _____________________________________________________________________________
What language(s) do you speak at home? _____________________________________________________________
How did you hear about Norwood CFCE Program Playgroup? _____________________________________________
Optional: These questions are so we can report to our funders the number of people who attend our programs who live in subsidized housing or who are currently taking English classes. The answer you give is confidential and will not affect your placement in a group.
Do you live in Public Housing, receive Section 8, or some other form of subsidized housing? YES NO
Are you currently taking a class to learn English? YES NO
I have read and I understand the information and agree to follow the rules and guidelines:
Signature: _______________________________________________ Date _____________________________
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