Early Learning Center | Family Access of Newton Online Payment

Enrollment Details

*This information is required

Enrolling (check one)*

Infant
Toddler
Preschool

Desired Enrollment Date*

Child's Name*

First Last

Date of Birth*

Contact Details

Parent/Guardian*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Home Phone*

Cell Phone*

Work Phone*

Languages spoken at home*

Please note medical history / special needs

Does your child take any medications*

Yes
No

List medications taken*

NOTE: Health forms are required, complete with all immunization dates and lead test. No child will be allowed to attend until the appropriate health form has been received and processed. Children must have had a physical within 12 months prior to attendance.

Has your child had previous child care (family or center-based) experience?*

Yes
No

Previous childcare center*

Additional Comments

How did you hear about Family ACCESS Early Learning Center? Check all that apply

NAEYC website
Referral
Online Discussion Group
Website Advertisement or listing
Google Search
Social Media
Signage or flyers
Drove by our building

Referral Name*

Online Discussion Group Name*

Social Media*

Facebook
Instagram

Billing Details

*This information is required

Non-Refundable Application Fee*

Price:

Billing Address*

Street Address Address Line 2 City State ZIP Code

Secure Credit Card

Card Holder*

Card Number*

Card Expiration*

Card CVV*

Upon receipt of this completed Online Application Form and payment of your $25 non-refundable application fee, your child will be waitlisted and you will be contacted by the Family ACCESS Enrollment Coordinator.

Total

$0.00

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