Gender : MaleFemale

What languages (if not English) does the child speak at home?

Is the child on any special diet?
YesNo
If yes, please indicate details below.

Does your child have any food allergies?
YesNo
If yes, please indicate details below.

Would you allow us to post a photo of your child to alert all staff of his/her allergy?

YesNo

What does your child use to drink? BottleSippy CupRegular Cup

How often does your child eat? Please give brief timetable below:

Does your child take a nap? YesNo
How many times a day?
How Long?

Does your child sleep with a special blanket, toy or pacifier?
YesNo
Are there any specific bedtime routines at home?
If yes please give brief explanation below:
Where does the child sleep at home?

Does your child use diapers? YesNo
Does your child use a potty or the toilet?

How does your child let you know that it is time “to go”?
Does your child need regular reminders to use the bathroom?

Do you have any concerns about your child’s development?
YesNo
HearingVisionLanguageGross motorFine motor SocialOther
Explain :
Has your child been in child care before?
YesNo
Is your child comfortable in group situations?
YesNo
Is there anything we should know about your child’s play with other children, by themselves, any concerns
What kid’s of activities does your child enjoy?
Are there activities your child avoids?
How would you describe your child’s temperament and personality?
Does your child have siblings?
YesNo

If yes, please list their names and ages below.
Does your family have any pets?
YesNo
If yes, pets name
What soothes your child?
What frightens your child?
Does your child have any favorite songs or games that comfort them?
YesNo
If yes, explain, What are your expectations or hopes for your child at our center?
What are your expectations for our children’s center and center staff members?

Has your child received all scheduled immunizations? YesNo
If no, your child will need to be excluded from the site during outbreaks of some infectious diseases.

Has your child received all scheduled immunizations?
YesNo
If yes, please explain

PARENT 1/GUARDIAN 1 DETAILS
(enrolling parent/guardian)

Mr./Mrs./Ms./Other:
Family Name:
Given Names:
Gender
Relationship to child:
Employment status:
Work location:
Work phone number:
Mobile number:
Nationality:
Does parent 1 speak a language other than English?:
Does this parent require an interpreter?
Email address:
Signature of enrolling parent/guardian:
Date:

PARENT 2/GUARDIAN 2 DETAILS

Mr./Mrs./Ms./Other:
Family Name:
Given Names:
Gender
Relationship to child:
Relationship to enrolling parent:
Employment status:
Work location:
Work phone number:
Mobile number:
Nationality:
Does parent 1 speak a language other than English?:
Does this parent require an interpreter?
Email address:

Mr./Mrs./Ms./Other:
Given Names:
Relationship to child:
Work location:
Work phone number:
Email address:
Family Name:
Gender

Employment status:
Work location:
Work phone number:
Nationality:
Mailing address:
Please indicate if this person wishes to receive reports and/or correspondence:

1.
Full Names:
Relationship to child:

Work phone number:
Mobile number:
Work location:

2.
Full Names:
Relationship to child:

Work phone number:
Mobile number:
Work location:

3.
Full Names:
Relationship to child:

Work phone number:
Mobile number:
Other Contact info:

4.
Full Names:
Relationship to child:

Work phone number:
Mobile number:
Other Contact info:

Full Names:
Relationship to child:

Work phone number:
Mobile number:
Clinic/Hospital Name:

No.

Child’s Name

Date Of Birth

Attends This Center?

YesNo

YesNo

YesNo

YesNo