Child’s Name _____________________________Nickname_______________________
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Previous Childcare History:
Has your child been in childcare before? __________If so, please give name, address and phone number of last childcare provider/center:
Name _________________________________ Phone Number _____________
Address _______________________________________________________
Dates attended from ________ to________ Why was care terminated? _______
______________________________________________________________
May I contact them for a reference? __________________________________
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Sleeping Habits:
Does your child have a regular bedtime schedule? _________________________
What time does your child usually go to bed at night? ______________________
What time does your child usually wake up in the morning? __________________
Does your child have trouble sleeping? _________________________________
Night terrors? _______________Trouble going to sleep? __________________
Other? ________________________________________________________
If under 18 months, how does your child prefer to sleep (back, stomach, side)? ______________________________________________________________
What time(s) and for how long does your child nap each day? _________________
Are there any favorite items that your child needs to go to sleep each day (pacifier, pillow, blanket, teddy bear, etc.)? _______________________________________
Has your child slept in a pack-n-play or on a mat before? _______________________
What is your child’s disposition upon waking (happy, clingy, slow to wake, etc.)? _____________________________________________________________________
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Health History:
Has or does your child have any known health condition? ____________________
___________________________________________________________________
Does your child need regular medication? If so, please explain why? ___________________________________________________________________
Does your child have any known allergies? ______________________________
_________________________________________________________________
Special instructions in case of allergic reaction __________________________
_________________________________________________________________
Has your child had or been exposed to any communicable diseases (chicken pox, measles, mumps, lice, etc.)? If so, please explain and provide dates.
___________________________________________________________________
Is your child prone to any common ailments (upset stomach, frequent colds, allergies, ear infections, sore throats, nose bleeds, diaper rash etc.)? ___________________________________________________________________
Is there any indication of hearing or vision problems? _____________________
_____________________________________________________________
Does your child have any physical or mental disabilities? ___________________
_____________________________________________________________
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Eating Habits:
What are your child’s eating habits (frequency and portion)? _________________
__________________________________________________________________
Does your child have any favorite foods? _______________________________
Does your child dislike any foods? ____________________________________
Does your child have a special diet? ___________________________________
______________________________________________________________
Are there any foods your child should not be fed? ________________________
________________________________________________________________
How does your child sit at the table (high-chair, booster seat, etc.)? ___________
________________________________________________________________
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General Information:
Do you have a back-up caregiver in the event that your child becomes ill and is unable to attend childcare or for provider’s holidays, vacations or personal days?
______________________________________________________________________
Are you looking for long-term or short-term care for your child? ___________________
_______________________________________________________________________
What are your expectations from My Little Peanut Daycare? _______________________
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