Echo Enrichment Center

a place for all ages and abilities

Echo Enrichment Center New Family Registration Form

Parents/Guardians____________________________________________________________________________________________
Address__________________________________________________________________________________________________________
Home Phone______________________________________________E-mail_______________________________________________
Work Phone_______________________________________________Cell Phone_________________________________________
Work Phone_______________________________________________Cell Phone_________________________________________

Emergency Contact Person________________________________________________________________________________
Home Phone_______________________________________________Cell Phone_________________________________________

Child________________________________________________________Male/Female______________________________________
Date Of Birth_____________________________________________Age At Enrollment_______________________________
Food Or Seasonal Allergies___________________________________________________________________________________
Important Information About Your Child (Fears, Developmental Delays, health related,etc...) 
That will assist us in his/her care________________________________________________________________________
Is your child receiving early intervention/outside services ?_______________________________________
We will support your child's development in these areas.
Child_________________________________________________________Male/Female________________________________________
Date Of Birth______________________________________________Age At Enrollment________________________________
Food Or Seasonal Allergies_____________________________________________________________________________________
Important Information About Your Child (Fears, Developmental Delays,health related etc..)
That will assist us in his/her care___________________________________________________________________________
Is your child receiving early intervention/outside services? ____________________________________________
We will support your child in these areas.
Photo Release  I do/do not give permission for my child(dren) to be photographed for news or program publication.Names of children will never be included in such photos.

Signature_______________________________________________________________Date___________________________________________________
Mailing Address: Echo Enrichment Center, 14 Lexington Street, Burlington, MA 01803