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Supplemental Form for Enrollment

Parent Information

Your Name (required)

Your Email (required)

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 Our Future Learning Center by:

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 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?: