NECP Application Form 2022-2023

	Newton Early Childhood Program

	150 Jackson Rd Newton, MA 02458 617-559-6050

1.	Child's Name (Last, First, Middle)*

2.	Gender*
	Female  Male

3.	Date of Birth (MM/DD/YYYY)*

4.	Primary Language*

5.	Parent(s)/Guardian(s) Name(s)*

6.	Full Address (Street, City, Zip)*

7.	Phone Number*

8.	Email*

9.	Has a sibling attended in the past?*
	Has a sibling attended in the past?* YesNo

10.	Sibling Name

11.	Please indicate your preferences*
	First Choice   Second Choice   Third Choice 8:30am-1:30pm 4 days/week (M-T, TH-F) & 8:30am-12:00pm 1 day/week (W)       9:00am-2:00pm 4 days/week (M-T, TH-F) & 9:00am-12:00pm 1 day/week (W)       9:00am-12:00pm Monday-Friday

12.	Has your child attended daycare or preschool previously? If so, where?

13.	Is your child presently receiving any therapeutic services (Speech Therapy, Occupational Therapy, etc.?) If yes, please list.

14.	Is there a history of therapeutic services (Speech Therapy, Occupational Therapy, Physical Therapy, etc.?)*

15.	How would you describe your child? *
	Yes/No   Comments socially outgoing     prefers being alone     very quiet and shy     active     overly active     seems happy     stubborn     fussy     independent     sleeps well     restless nights/nightmares     any unusual behaviors (head banging, rocking, etc.)

16.	Additional Comments or Concerns