* = Required Information
Child Information
Child's First and Last Name
*
Child's Date of Birth
*
Age at Admission
Date of Admission
Child’s Home Address
Home Phone Number
Primary Language
Identifying Marks
Eye Color
Hair Color
Skin Color
Sex
Height
Weight
Parent/Guardian Information
Parent/Guardian 1 Name
Relationship to Child
Home Address
Reachable Phone Number
Email Address
Business Name
Business Address
Business Phone Number
Hours at Work
Parent/Guardian 2 Name
Relationship to Child
Home Address
Reachable Phone Number
Email Address
Business Name
Business Address
Business Phone Number
Hours at Work
Additional Information
Child’s Physician
Address
Phone Number
Allergies?
Any special (Vegetarian, no meat) Diets?
Do you need an Individual Health Plan for your child or do you have an IEP (Individualized Education Plan) for your child? This would apply to children with a chronic health condition like Asthma, peanut allergies, etc or a plan IEP from an authorized therapist
Copies of any custody agreements, court orders, and restraining orders pertaining to the child?
Special limitations or concerns?
My child will arrive and depart from KiddieTime Educational Child Care
Developmental Information
Age Child began sitting
Age Child began crawling
Age Child began walking
Age Child began talking
Does your child pull up
Does your child crawl?
Does your child walk with support?
Any speech difficulties?
Special words to describe needs
Any history of colic?
Does your child use pacifier or suck thumb?
When do they use a pacifier or suck thumb?
Does your child have a fussy time?
When are they fussy?
How do you handle this time?
Health Information
Any known complications at birth?
Serious illnesses and/or hospitalizations?
Special physical conditions, disabilities
Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions
Regular medications?
Eating
Any Special characteristics or difficulties eating?
If infant is on a special formula, describe its preparation in detail
Favorite foods
Foods refused
Is your child fed held in lap?
Is your child fed held in High chair?
Does your child eat with a spoon?
Does your child eat with a fork?
Does your child eat with their hands?
Diapering/Toileting
Are disposable or cloth diapers used?
Do they have frequent occurrence of diaper rash?
Do you use baby oil?
Do you use baby powder?
Do you use baby lotion?
Do you use baby powder
Do you use anything else for diaper rash?
Are bowel movements regular?
How many per day?
Is there a problem with diarrhea?
Is there a problem with constipation?
Has toilet training been attempted?
Please describe any particular procedure to be used for your child at the center
While toileting at home, do you use a Pottychair?
While toileting at home, do you use a Special child seat?
Regular seat?
How does your child indicate bathroom needs (include special words)?
Is your child ever reluctant to use the bathroom?
Does your child have accidents?
Sleeping Habits
Does your child sleep in a crib?
Does your child sleep in a bed?
Does your child become tired or nap during the day (include when and how long)?
When does your child go to bed at night?
And get up in the morning?
Describe any special characteristics or needs (stuffed animal, story, mood on waking etc):
Social Development
How would you describe your child's personality?
Previous experience with other children/day care?
Reaction to strangers
Able to play alone?
Favorite toys and activities
Fears (the dark, animals, etc.)
How do you comfort your child?
What is the method of behavior management/discipline at home?
What would you like your child to gain from this childcare experience?
Daily Schedule
Please describe your child’s schedule on a typical day. For infants, please include awakening, eating, time out of crib/bed, napping, toilet habits, fussy time, night bedtime, etc.
Is there anything else we should know about your child?
First Aid, Emergency and Medical Care
We will contact you in an emergency, is there a specific hospital/medical facility you prefer we take your child?
Emergency Contacts (In order to be contacted)
Name
Address
Relationship to child
Home Phone
Cell Phone
Do you give permission for child to be released to this person?
Name
Address
Relationship to child
Home Phone
Cell Phone
Do you give permission for child to be released to this person?
Name
Address
Relationship to child
Home Phone
Cell Phone
Do you give permission for child to be released to this person?
Health Insurance Company
Health Ins Policy Number
Do you wish your child to have their teeth brushed at school?
Do you wish diaper Cream to be applied?
Do you wish sunscreen to be applied in the summer?
Do you wish any lotion to be applied?
Do you wish any other lotion to be applied?
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