Convergence Childcare Form
Please fill out this basic information as soon as possible to help us provide a safe and enjoyable environment for your child(ren)!
Name of child(ren), gender and age(s)
Person responsible for child at the Convergence and phone number where we can reach you at the Convergence
Name(s) of anyone else who can pick up your child at Convergence childcare.
Name of your physician and medical number
Please list any allergies or dietary restriction of your child (if multiple children, please list each child).
Is there any information about eating, napping, toiletry habits or behavior we might want to know about (please list each child)?
Does your child(ren) have any medical issues we should be aware of (eg, asthma or diabetes)?
Is there anything else you want to tell us about your child(ren)? Their favorite activities? How they relate with other children? With nature? Is there anything we can do to help meet your child(ren)'s social or emotional needs?
Thank you! If you have any questions or concerns please write them down below or email Diana:
; or 415-902-8141.
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