Child's Enrollment Form

Child Information

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 Information

Parent/Guardian Name

Relationship to Child

Reachable Phone Number

Home Address

Email Address

Business Name

Business Address

Business Phone Number

Hours at Work

Parent/Guardian Name

Relationship to Child

Reachable Phone Number

Home Address

Email Address

Business Name

Business Address

Business Phone Number

Hours at Work

Additional Information

Child's Physician

Address

Phone Number

Allergies/Special Diets?

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

File upload

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

File upload

Special limitations or concerns?

School Age Only

Current School

School Address

School Phone Number

Student Photo

Please provide Mansfield Little School with a photo of the student you are enrolling with us.

I certify that documentation of physical examination and immunizations in accordance with public school health requirements and lead poisoning screening in accordance with public health requirements are on file at my child’s school. Parent/Guardian initials:

Signature

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Date

Month

Day

Year