Family Information
By providing complete information about your child, you will be assisting staff in creating a positive experience for him/her while in care. List any information about your child's habits, abilities or personality that you feel will be helpful to the staff while caring for your child. Questions that do not apply to your child should be answered with N/A.
What's your child's name? *
Your answer
Which school of ours is your child attending? *
Who is in your child's immediate family? *
Your answer
Who lives at home with your child? *
Your answer
What is the primary language spoken in your child's home? *
Your answer
Are there any special family arrangements, such as shared parenting, living in two homes, or custody specifications, etc? *
Your answer
Are there any changes or transitions that your child has recently experienced or is experiencing? *
Your answer
Are there any cultural or religious practices of your family we should be aware of? (Dietary restrictions, clothing, head coverings, etc.) *
Your answer
Do you have any pets at home? If so, what are they and what are their names? *
Your answer
Has your child had a previous care arrangement? (Center based, in home, with family, with parents, etc.) Additional details please *
Your answer
My child drinks (check all that apply) *
Required
How much does your child drink and how often? *
Your answer
Does your child have any favorite foods? *
Your answer
Does your child dislike any foods? *
Your answer
Are there any foods your child should not be fed? (Licensing requires documentation be completed for children with food allergies and/or dietary restrictions) Please ask center Director an additional form for these. *
Your answer
Please check all of the words that bet describe your child's personality and behavior *
Required
Are there additional personality and behavior characteristics that would be useful to know about your child? *
Your answer
Are there things that frighten your child? If so, how does he/she react and what do you do to comfort him/her? *
Your answer
What routines/actions or items do you use to comfort your child? *
Your answer
What causes your child to feel angry or frustrated? *
Your answer
What methods do you use to respond to your child's negative behavior? *
Your answer
Does your child use any special comfort or support items that help him/her go to sleep? If so, what? *
Your answer
What is your child's mood upon waking? (happy, grouchy, clingy, slow to awaken) *
Your answer
My child sits in a (check all that apply) *
Required
Is your child toilet trained? *
If not, have you started the toilet training process? Please explain process used. *
Your answer
Does your child need assistance when using the toilet? If so, how? *
Your answer
What words, gestures or signs does your child use if he/she needs to use the bathroom? *
Your answer
What time does your child normally go to bed at night and wake up in the morning? *
Your answer
What time(s), and for how long, does your child usually nap? *
Your answer
Does your child have trouble sleeping (night terrors, trouble going to sleep, etc)? Please explain *
Your answer
What might you and/or your child be anxious about as he/she starts in this program? *
Your answer
What are you and/or your child excited about as he/she starts in this program? *
Your answer
What are your expectations of this program? *
Your answer
What other information would be helpful for the staff caring for your child to know? *
Your answer
Please mark date of completion of this form. *
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Please enter the full name below of the parent/guardian completing this form. *
Your answer
Please enter the last four digits of your social security number for authentication of your electronic signature. *
Your answer
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