Enrollment Form

Date______________________

Child’s Name _______________________________________________

Child’s age_______________________________

Child’s Birthday________________________ Nickname____________________

Address_______________________________________________________________

Contact Info:

Mom’s name _______________________________________________

Dad’s name________________________________________________

(Mother)Home Phone_____________________________________

(Mother)Work Phone_____________________________________

(Mother’s) Cell Phone_____________________________________

(Father)Home Phone_____________________________________

(Father)Work Phone_____________________________________

(Father’s) Cell Phone_____________________________________

Emergency Contact Person #1 _________________________________

Contact’s phone_________________________________________

 Emergency Contact Person #2 _________________________________

Contact’s phone_________________________________________

Do you have a backup care provider?

__________________________________________________________

Service Info:

Beginning date needing care ________________

Days and Hours:

Monday__________Tuesday_________________Wednesday_______________

Thursday_________Friday_______________Saturday_____________________

Times you plan to drop your child off________

Times you plan to pick up your child_________

Your Child’s Health

CHILD'S HEALTH RECORD: (A copy of your child's immunizations)

General state of health: ____________________________________________________________________________________________________________________________________________
______________________________________________________________________

Doctor’s name_____________________________________________________

Doctor’s phone number_______________________________________________

Dentists’ name_____________________________________________________

Dentists’ name _____________________________________________________

Are your child's immunizations up to date? _________ (Please attach a copy of immunizations.)
Does your child have any known allergies? __________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you concerned that your child may be prone to any type of allergies?
_______________________

Describe:

____________________________________________________________________________________________________________________________________________
______________________________________________________________________

Does your child have any medical conditions which I should be made aware of? ___________________________________________________________________________________________________________________________________________________________________________________Has your child had the following common childhood illnesses?
.(please circle)

Does your child have any speech, hearing or visual problems? ____________________________________________________________________________________________________________________________________________________________________________________

Would there be any restrictions to play or activities? ____________________________________________________________________________________________________________________________________________________________________________________

About Your Child

Has your child ever been in childcare before? _________ What type (center, family daycare, grandma etc.) _____________

Was it a positive experience?

Why are you looking for childcare?

____________________________________________________________________________________________________________________________________________________________________________________

How does your child feel about daycare and being left by his/her mommy/daddy?

______________________________________________________________________

______________________________________________________________________

Are there any recent traumatic situations the child has been exposed to such as a death in the family, divorce, new sibling etc.? ______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc. ____________________________________________________________________________________________________________________________________________________________________________________

Are there any food restrictions?

____________________________________________________________

What is your child's favorite food? ________________________________________________________________________________________________________________________

What food does your child dislike? ____________________________________________________________________________________________________________________________________________________________________________________

Can your child be relied upon to indicate bathroom needs? ________________________________________

What words does your child use for: Bowel movements _______ urination___________

What time does your child wake up at? ___________________________________________

What time does your child go to sleep at night? __________________________________

Do they sleep through the night? _____________________________________________

Does your child sleep in a bed or crib, other? ____________________________________

Are there any siblings? Please name them and specify ages and gender.

Name _____________________ age _____         gender _______

Name ______________________ age _____     gender ______

Name ______________________ age _____   gender _______

Has your child had experience playing with other children?
________________________________________________________________________________________________________________________

What language(s) are spoken at home? ____________________________________________________________

Does your child have any security objects such as a blanket, soother, bottle, toy etc.? ____________________________________________________________________________________________________________________________________________________________________________________

What are your child's favorite activities, toys, books, or games? ________________________________________________________________________________________________________________________

Any specific concerns?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________