"Family Child Care Enrollment Packet"

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*P H O T O OF C H I L D
(*Optional)
FAMILY CHILD CARE
Children’s Records must
P L U S
be maintained for at least
ENROLLMENT PACKET
P H Y S I C A L
five (5) years after a child
D E S C R I P T I O N
has left the program
F A C E
S H E E T
Eye Color _______
Please fill out these forms completely. If a question does not apply
Hair Color ______ Sex_____
to your child, write N/A (not applicable). The forms must be in the
Height _____ Weight _______
educator’s possession on or before the first day your child begins
Other:____________________
care. Please notify your educator if any of the information changes.
_________________________
_________________________
General Information
Date of Admission ________________ Age at Admission: ______
Date of Discharge ______________
Reason for Discharge: _________________________________________________________________
____________________________________________________________________________________
Child's full name ______________________________Date of Birth ______________________________
Address:_______________________________ City:___________________
Zip:________________
Telephone Number: ______________________________ Nickname __________________
Primary Language of Child _____________
Primary Language of Parents_________________
Allergies/Special Diets _________________________________________________________________
Name of Parent(s)/Guardian(s)___________________________________________________________
Home address (if different) ______________________________________________________________
Telephone Number:____________________________________________________________________
Email Address: _______________________________________________________________________
Parent(s)/guardian(s) business address/location during child care:
Parent/Guardian: __________________________
Parent/Guardian ____________________________
Where: __________________________________ Where: ___________________________________
Telephone: _______________________________ Telephone:_________________________________
Cell Phone: _______________________________ Cell Phone:________________________________
Instructions: _______________________________ Instructions:________________________________
_________________________________________ __________________________________________
Emergency Contact/Authorized pick-up person
In the event of an emergency when I may not be reached, the Educator may contact the following
individuals (in the order given) whom I authorize to take my child from the child care premises.
(1) Name: _______________________________ Address _____________________________________
Telephone ______________Cell Phone __________
(2) Name: ______________________________ Address ______________________________________
Telephone _____________ Cell Phone __________
Child’s Name ______________________
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*P H O T O OF C H I L D
(*Optional)
FAMILY CHILD CARE
Children’s Records must
P L U S
be maintained for at least
ENROLLMENT PACKET
P H Y S I C A L
five (5) years after a child
D E S C R I P T I O N
has left the program
F A C E
S H E E T
Eye Color _______
Please fill out these forms completely. If a question does not apply
Hair Color ______ Sex_____
to your child, write N/A (not applicable). The forms must be in the
Height _____ Weight _______
educator’s possession on or before the first day your child begins
Other:____________________
care. Please notify your educator if any of the information changes.
_________________________
_________________________
General Information
Date of Admission ________________ Age at Admission: ______
Date of Discharge ______________
Reason for Discharge: _________________________________________________________________
____________________________________________________________________________________
Child's full name ______________________________Date of Birth ______________________________
Address:_______________________________ City:___________________
Zip:________________
Telephone Number: ______________________________ Nickname __________________
Primary Language of Child _____________
Primary Language of Parents_________________
Allergies/Special Diets _________________________________________________________________
Name of Parent(s)/Guardian(s)___________________________________________________________
Home address (if different) ______________________________________________________________
Telephone Number:____________________________________________________________________
Email Address: _______________________________________________________________________
Parent(s)/guardian(s) business address/location during child care:
Parent/Guardian: __________________________
Parent/Guardian ____________________________
Where: __________________________________ Where: ___________________________________
Telephone: _______________________________ Telephone:_________________________________
Cell Phone: _______________________________ Cell Phone:________________________________
Instructions: _______________________________ Instructions:________________________________
_________________________________________ __________________________________________
Emergency Contact/Authorized pick-up person
In the event of an emergency when I may not be reached, the Educator may contact the following
individuals (in the order given) whom I authorize to take my child from the child care premises.
(1) Name: _______________________________ Address _____________________________________
Telephone ______________Cell Phone __________
(2) Name: ______________________________ Address ______________________________________
Telephone _____________ Cell Phone __________
Child’s Name ______________________
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TRANSPORTATION PLAN / AUTHORIZED PICK- UP
My child will arrive to the program by:
My child will depart the program by:
__Parent Drop-Off
__Parent Pick Up
__Supervised Walk
__Supervised Walk
__Unsupervised Walk
__Unsupervised Walk
__Public/Private Van
__Public/Private Van
__Bus
__Program Bus/Van
__Private Transportation Provided by Parent
__Private Transportation Provided by Parent
In the space below, please note any important information regarding transportation of your child to and
from the program (i.e.--indicate who will be supervising children during transport or prior to their arrival at
the program, who supervises the walk from a bus stop, etc.)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________________________________________
I additionally authorize the following individual to take my child from the child care premises. (Please let
me know at the beginning of the day when your child will be picked up by one of the authorized
individuals.)
Name _____________________________ Address ________________________________________
Telephone ______________ Cell Phone ____________________
Name _____________________________ Address ________________________________________
Telephone ______________ Cell Phone ____________________
Anticipated Days/Time of Attendance
Day
Arrival Time
Departure Time
Day
Arrival Time
Departure Time
Monday
____________ ____________
Friday
___________ ____________
Tuesday
____________ ____________
Saturday
__________
____________
Wednesday
____________ ____________
Sunday
___________ ____________
Thursday
____________ ____________
If applicable: Name of School Child Attends: ________________________________________________
Copies of any custody agreements, court orders, restraining orders (if applicable)
Notes:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Child’s Name ____________________
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Written Acknowledgement of Receipt of Parent Handbook
I acknowledge that I have received a copy of the provider’s parent handbook as well as information
regarding lead poisoning prevention (may be included in the parent handbook).
_______________________________________________
______________
Parent/Guardian
Date
Parental Visit Notice
I understand that I may visit this family child care home unannounced at any time during the hours that
my child is in care.
______________________________________________
_______________
Parent/Guardian
Date
Child's Physician or Health Care Professional
Name: ______________________________________________ Telephone: ___________________
Address: ___________________________________________
Information on allergies, special diets, chronic health conditions, special limitations, concerns including
medications child is taking at home/school and possible side effects:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Medical Insurance Information (OPTIONAL)
Subscriber's Name: _________________________________ Policy #: _____________________
Type of Insurance: _________________________________
[ ] Copy of Insurance Card
SCHOOL AGE ONLY
Current School: ____________________________
School Address: _________________________
______________________________________
I certify that documentation of physical examination and immunizations in accordance with public school
health requirements, and lead poisoning screening in accordance with public health requirements are on
file at my child’s school.
Parent/Guardian initials: ________________
Child’s Name ______________________
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DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION
Regulations for licensed child care programs require this information to be on file to address the needs of
children while in care.
CHILD'S NAME _______________________________________
DATE OF BIRTH _____________
*Note: Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child.
DEVELOPMENTAL HISTORY
Age began sitting ________ crawling ______ walking _________ talking ____________
*Does your child pull up? ________ *Crawl? ______ *Walk with support? _______
Any speech difficulties?______________________________________________________________________
Special words to describe needs ______________________________________________________________
Language spoken at home _______________________ *Any history of colic? __________________________
*Does your child use pacifier or suck thumb? _____________ *When? ________________________________
*Does your child have a fussy time? ____________________ *When? ________________________________
*How do you handle this time? ________________________________________________________________
HEALTH
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 HABITS
Special characteristics or difficulties: ___________________________________________________________
*If infant is on a special formula, describe its preparation in detail _____________________________________
________________________________________________________________________________________
Favorite foods: ____________________________________________________________________________
Foods refused: ____________________________________________________________________________
* Is your child fed held in lap? ______________
High chair? ____________________
* Does your child eat with Spoon? _____________________ Fork? ______________ Hands? _____________
TOILET HABITS
*Are disposable or cloth diapers used? _________________
*Is there a frequent occurrence of diaper rash? ____________________________
*Do you use: baby oil ________ powder ______________
lotion ________________ Other _____________
*Are bowel movements regular? ________________ how many per day? _______________
*Is there a problem with diarrhea? _______________ Constipation? ____________________
*Has toilet training been attempted? _____________
*Please describe any particular procedure to be used for your child at the program
__________________________________________________________________________________________
What is used at home? Potty chair? _______ 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 the child have accidents? _________________________________________________________________
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SLEEPING HABITS
*Does your child sleep in a crib? ________ Bed? ________
Does your child become tired or nap during the day (include when and how long)? _____________________
_______________________________________________________________________________________
Please Note: The American Academy of Pediatrics has determined that placing a baby on his/her back
to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden and
unexplained death of a baby under one year of age. If your child does not usually sleep on his/her
back, please contact your physician immediately to discuss the best sleeping position for your baby.
Please also take the time to discuss your child’s sleeping position with your educator. Your educator
will place your infant on his/her back unless there is a written physician’s order that specifies
otherwise.
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 walking etc) ________________
________________________________________________________________________________________
SOCIAL RELATIONSHIPS
How would you describe your child:____________________________________________________________
________________________________________________________________________________________
Previous experience with other children/child 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 child care 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?___________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Parent/Guardian Signature: __________________________________
Date: _____________________
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