The Commonwealth of Massachusetts

Department of Early Education and Care

Child’s Name*

Date of Birth*

Age at Admission

Date of Admission

Home Phone Number

Child’s Home Address

Primary Language

Identifying Marks

Eye Color

Hair Color

Skin Color

Sex

Height

Weight

Parent/Guardian Name*

Relationship to Child

Home Address

Reachable Phone Number

Email Address

Business Name

Business Address

Business Phone Number

Hours at Work

Parent/Guardian Name (2)

Relationship to Child

Home Address

Reachable Phone Number

Email Address

Business Name

Business Address

Business Phone Number

Hours at Work

Child’s Physician

Address

Phone Number

Allergies/Special Diets?

Individual Health Plan for child with a chronic health condition? If yes, please attach.

Copies of any custody agreements, court orders, and restraining orders pertaining to the child? If yes, please attach.

Special limitations or concerns?

Current School

School Address

School Phone Number

Parent/Guardian Initials (certifies physical exam, immunization, and lead screening documentation is on file at child’s school)

Parent/Guardian Signature

Date

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