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have ________ brothers_________sisters.
Their names are__________________________________
___________________________________________________________________________________
How would you describe your child’s personality?____________________________________________
___________________________________________________________________________________
Has your child been in childcare
before?__________yes____________no
If yes, please give last provider or center’s information:
Name________________________________________________Phone__________________________
Dates attended:
From_____________________To__________________________
Why was this childcare terminated? _______________________________________________________ ____________________________________________________________________________________
Does your child have a regular bedtime
schedule?_____________yes_______________no
What time does your child usually go to bed at
night?_______________________________
What time does your child usually wake up in the
morning?__________________________
Does your child have trouble
sleeping?________________ Night terrors?_______________
Does your child take regular naps?______________ If
so what times of day?______________________
How long are the
naps?_____________________________________________
If an infant, how does your child sleep? (Circle
One) stomach side back
Are there any special doll, blanket, etc. that your
child needs to go to sleep?_______________________
What is your child’s disposition upon waking up?
(Circle One)
happy
grouchy clingy
other___________________________
Does your child have any known health problems?
___________yes________________no
If yes, please
explain___________________________________________________________________
____________________________________________________________________________________
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
allergies________________________________________________________________
____________________________________________________________________________________
Special instructions in case of an allergic
reaction_____________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Has your child had any of the following
communicable diseases? (circle all that apply)
Chickenpox Measles Mumps Other_______________________
Is your child prone to any of the following?
(circle all that apply)
colds upset stomach seasonal allergies earaches
sorethroats other______________________
Are there any indications of hearing or vision
problems?_________________yes_____________no
Has your child had any recent
illnesses?_____________yes_________________no
If yes, please
describe________________________________________________________________
__________________________________________________________________________________
Does your child have any physical or mental
disabilities?_______________yes________________no
If yes, please
describe_______________________________________________________________
_________________________________________________________________________________
Do you have a back up plan if your child is ill and
cannot attend or becomes ill and must be picked up?
__________________________________________________________________________________
__________________________________________________________________________________
What are child’s eating habits? (minds trying new
things, times usually eats, etc.)__________________
__________________________________________________________________________________
__________________________________________________________________________________
If an infant, what kind of formula is your child
on?___________________________________________
Child’s usual dining habits? (circle all that
apply) high chair booster seat feeds self
uses utensils sipper cup
regular cup
other_______________________________
Does your child eat
unaided?_____________yes____________________no
Does your child enjoy
eating?______________yes_____________________no
Does your child have a special
diet?____________________yes_______________________no
Are there any foods that should not be fed to your
child?_____________yes_______________no
If yes, please list
them_________________________________________________________________
___________________________________________________________________________________
Child’s favorite
foods__________________________________________________________________
___________________________________________________________________________________
Strong
dislikes_______________________________________________________________________
___________________________________________________________________________________
How do you reward your
child?__________________________________________________________
___________________________________________________________________________________
How do you discipline your
child?_________________________________________________________
____________________________________________________________________________________
What are your expectations of this program and of
me?________________________________________
________________________________________________________________________________________________________________________________________________________________________
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