Child Information Sheet
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Today's Date
MM
/
DD
/
YYYY
Child's Name *
Name of person who brought child today *
Child's Date of Birth *
MM
/
DD
/
YYYY
Parents' Names *
Street Address *
City
ZIP
Home Phone
Cell Phone
Email Address
Custodial Concerns? *
Required
Photo consent?  (activity photos will be taken on occasion) *
Allergies?  If yes, please describe
Food Restrictions?  If yes, please describe
The following section is for nursery age only, complete as needed
Child is in:
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Is child:
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Child may need a nap by
Time
:
Prefers to sleep on:
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Child may need to eat by
Time
:
Does your child use a bottle or are they nursing?
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If on a bottle, how often does baby need to be burped?
type number of ounces
Any other special instructions for feeding?
Favorite activities: (ex: swinging,bouncy seat, crawling, etc)
Please provide any other information we need to know to care for your child properly:
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