Date of Enrollment:                                           

Child’s Name:                                                                Birthdate:                                            
Social Security Number:                                                                                                            
Mother’s Name:                                                                                                                        
Mother’s Complete Address:                                                                                                                                                                                                                                                      
Mother’s Phone #:         Home                            Work                            Cell                              
Mother’s Social Security Number:                                                                                              
Father’s Name:                                                                                                                        
Father’s Complete Address:                                                                                                                                                                                                                                                                                                                             
Father’s  Phone #:         Home                            Work                            Cell                              
Father’s Social Security Number:                                                                                               
Mother’s Employer:                                                                                                                   
Employer’s Complete Address:                                                                                                                                                                                                                                                                                                                          
Days and Hours of Employment:                                                                                                 
Father’s Employer:                                                                                                                   
Employer’s Complete Address:                                                                                                                                                                                                                                                                                                                           
Days and Hours of Employment:                                                                                                 
Do they have brothers & sisters?  If so, what are their sex/ages?                                                                                                                                                                                                                                                                        
Are there other adults in the home?                                                                               

General Information
What holidays do you celebrate?

Are there any holidays you DO NOT want to participate in?                                                                                                                                                                                                                                                                                  
Type of pets at home?                                                                                                               
Special FAMILY situations? (such as custody specifications, problems arising from situations, etc.)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
Any other information about your family or child that you wish us to know:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

Child’s Disposition
Does your child have any particular habits or mannerisms such as thumb sucking or nail biting? If so please describe                                                                                                                                                                                             
How does your child express ANGER or frustration?                                                                     
Does your child have any special FEARS?                                                                           Explain                                                                                                                                                                                                                        
Do you anticipated ADJUSTMENT problems?                                                                                                                                                                                                                                                                                                        
Please add any comments that may help me to understand your child. (Ex. Calming techniques etc.)                                                                                                                                                                                                                                                                                                                                                                                                         
Has your child had experience playing with other children? ( ) yes ( ) no
If yes, please specify:                                                                                                               
How does your child show when he/she is:
Afraid?                                                                                                                                     
Happy?                                                                                                                                     
Angry?                                                                                                                                      
Tired?                                                                                                                                      
Sick?                                                                                                                                        
How does your child feel about daycare?                                                                         
Are there any recent traumatic events that have occurred within your life that could affect your child?  ( ) yes ( ) no
If yes, what?                                                                                                                             
Does your child have any special toys, blanket, etc.?        ( ) yes ( ) no
If yes what?                                                                                                                              

Child’s Sleep Habits
What time does your child go to bed at night?                                                                            
How do you put your child to sleep?                                                                                            
What is their mood when they are put to bed?                                                                            
Does your child sleep through the night?                                                                         
What time does your child wake up in the morning?                                                                    
Where (on what) does your child sleep?                                                                                      
Does your child take a nap? ( ) yes ( ) no If yes, when?                                                                                                                                                                                                                                                                                        
Special toy or blanket for NAP? ( ) yes ( ) no
If yes what is the special item?                                                                                                  
If infant, how does your child sleep?  stomach  side  back   
What is your child’s disposition upon waking up? (happy, crying, grouchy, clingy, slow waking)                                                                                                                                                                                                                    

Child’s Toilet Habits
Is your child TOILET TRAINED? ( ) yes ( ) working on it ( ) no
If no, when do you plan to start potty training?                                                                             
Does your child have any fears relating to potty training?                                                                                                
If yes or working on it:
Does your child have any accidents?  When?                                                                                
What word does your child use for:
Bowel movements?                                            
Urination?                                                             
Soiled Diaper?                                                   

Child’s Activities
What are your child’s favorite toys, games, activities, books?                                                                                                                                                                                                                                                                                                                                                                                                                                                                
What activities does your child spend most of his waking hours doing at home?
                                                                                                                                                                                                                                                                                                                                                                       

Does you child like:
To go to the park? ( ) yes ( ) no
Play outside? ( ) yes ( ) no
Listening to books? ( ) yes ( ) no
Play with other children? ( ) yes ( ) no

Child’s Past Child Care Experiences
Has child stayed with any other adults besides parents? ( ) yes ( ) no
If yes please specify:                                                                                                                
Has your child been in childcare before? ( ) yes ( ) no
If yes, please give last childcare provider, or daycare center’s information:
Name: _____________________________________ Phone (         )                          
Dates attended: from                  to                     
Why was care terminated?                                                                                             
May I contact them for a reference? ( ) yes ( ) no

Behavior/Discipline

What are your methods of reassuring and rewarding your child?                                                                                        
                                                                                                                                                                                                                                                                                                                                                                       
What are your methods of responding to your child’s negative behavior?                                                                                                                                                                                                                                                             
What forms of discipline are most often used in your home?                                                                                                                                                                                                                                                                              
Do you have any outstanding concerns?                                                                                                                                                                                                                                                                                                               

Back-up Care Information
Do you have a back-up provider for my holidays and vacation days? 
( ) yes ( ) no
If yes, Name, address, and phone number:                                                                                                                                                                                                                                                                                                         
Have you made any arrangements for child care during illness (who should we call in case emergency pickup is needed due to illness)?:                                                                                                                                                                                              
If no:
Would you like some names and numbers of other providers? ( ) yes ( ) no

Child’s Health
Has or does your child have any known health problems? ( ) yes ( ) no
If yes, please describe:                                                                                                                                                                                                                                                                                                
Does your child need regular medication? ( ) yes ( ) no
If yes, what and when is it given?                                                                                    
Does your child have any known allergies? ( ) yes ( ) no
If yes, please list allergens:                                                                                 
Special instructions in case of an allergic reaction:                                                                                                                                                            
                                                                                                                                                          
Are there any indications of hearing or vision problems? ( ) yes ( ) no
If so, please explain:                                                                                          
Has your child had any recent illnesses? ( ) yes ( ) no
If yes, describe:                                                                                                             
Does your child have any physical or mental disabilities? ( ) yes ( ) no
If yes, please explain:                                                                                         
Last Physical Examination:                                                                                            
Medicine allergies:                                                                                                                    
Has your child had any of the following illnesses or conditions: (please circle)
Constipation
Head Lice
Convulsions
Ringworm
Diarrhea
Skin Rash
Fainting Spells
Soiling
Frequent Colds
Stomach Upsets
Frequent Ear Infections
Urinary Problem
Frequent Sore Throats
Worms
Asthma
Bronchitis
Chicken Pox
Diabetes
Heart Disease
Hepatitis
Impetigo
Measles
Mumps
German Measles
Polio
Scarlet Fever
Tuberculosis
Whooping Cough

Other ILLNESSES? (besides above)
                                                                                                                                                                                   
Has your child been HOSPITALIZED? (explain)
                                                                                                                                                                                   
Any disorders/developmental (slow, advanced) diagnosed or suspected?                                                                                                                                                                                                                                                              
Has your child had INJURIES with fractures or loss of consciousness? (explain)
                                                                                                                                                                                                                                                                                                                                                                      
Any other members of your family with SERIOUS ILLNESS recently?
                                                                                                                                                                                                                                                                                                                                                                         
Any other members of your family history of:
ASTHMA ( ) yes ( ) no    DIABETES ( ) yes ( ) no   EPILEPSY ( ) yes ( ) no

Emergency/Medical Information:
If neither parent or guardian can be reached in case of an emergency call:                                                                                                                                                                                                  
Child’s Doctor (name, full address, phone):                                                                                        
Child’s Dentist (name, full address, phone):                                                                                       
Child’s Hospital of Choice(name, full address, phone):                                                                       
Insurance Information:                                                                                                              

Child’s Eating Habits
What are your child’s eating habits? (mind trying new things, times usually eats, etc.)                                                                                                                                         

Child’s usual dining habits: (circle all that apply)

high chair
booster seat
feeds self
uses utensils
bottle
sippy cup
regular cup