275 Prospect Street, PO Box 67, Norwood, MA 02062
781.762.6804 Phone | 781.762.0229 Fax

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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