Infant Enrollment Intake Form

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Infant Enrollment Intake Form
Child’s Name: ___________________________ Date of Birth:________________ Gender:
M
F
Eating
Is your child on any special diet? ____Vegetarian ____ovo-lacto ____vegan ____other
Does your child have any food allergies? _______ If yes, please describe _____________________________
__________________________________________________________________________________________
Would you allow us to post a photo of your child to alert all staff to his/her allergy?
Yes
No
What does your child use to drink?
____bottle
____ sippy cup ____ regular cup
____nursing
_____other:___________________
How often does your child eat? _______________________________________________________________
Has your infant started on any other foods besides formula or breast milk? _____________________________
_________________________________________________________________________________________
Sleeping
Does your child nap?
Yes
No
How many times per day? _________ How long?____________
Does your child sleep with a special blanket, toy or “lovey”, or pacifier?
Yes
No
Are there specific bedtime routines at home? ____________________________________________________
__________________________________________________________________________________________
Where does your child sleep at home
?_______________________________________________________________________
Toileting
Does your child use diapers?
Yes
No
____Cloth ____Disposable ____Pull ups
If cloth, remember that we are unable to launder diapers and they will be bagged and sent home un-rinsed and
un-emptied.
Are there any specific ointments or lotions your family uses: _______________________________
Development
Do you have any concerns about your child’s development?
Yes
No
____Hearing ____Vision ____Language ____Gross Motor ____Fine Motor ____Social ____Other
__________________________________________________________________________________________
__________________________________________________________________________________________
Is there anything about your child's birth that you would like to share?__________________________
__________________________________________________________________________________________
What is your child’s primary spoken language? ___________________________________________________
Are there other languages being used with your child_______________________________________________
Infant Enrollment Intake Form
Child’s Name: ___________________________ Date of Birth:________________ Gender:
M
F
Eating
Is your child on any special diet? ____Vegetarian ____ovo-lacto ____vegan ____other
Does your child have any food allergies? _______ If yes, please describe _____________________________
__________________________________________________________________________________________
Would you allow us to post a photo of your child to alert all staff to his/her allergy?
Yes
No
What does your child use to drink?
____bottle
____ sippy cup ____ regular cup
____nursing
_____other:___________________
How often does your child eat? _______________________________________________________________
Has your infant started on any other foods besides formula or breast milk? _____________________________
_________________________________________________________________________________________
Sleeping
Does your child nap?
Yes
No
How many times per day? _________ How long?____________
Does your child sleep with a special blanket, toy or “lovey”, or pacifier?
Yes
No
Are there specific bedtime routines at home? ____________________________________________________
__________________________________________________________________________________________
Where does your child sleep at home
?_______________________________________________________________________
Toileting
Does your child use diapers?
Yes
No
____Cloth ____Disposable ____Pull ups
If cloth, remember that we are unable to launder diapers and they will be bagged and sent home un-rinsed and
un-emptied.
Are there any specific ointments or lotions your family uses: _______________________________
Development
Do you have any concerns about your child’s development?
Yes
No
____Hearing ____Vision ____Language ____Gross Motor ____Fine Motor ____Social ____Other
__________________________________________________________________________________________
__________________________________________________________________________________________
Is there anything about your child's birth that you would like to share?__________________________
__________________________________________________________________________________________
What is your child’s primary spoken language? ___________________________________________________
Are there other languages being used with your child_______________________________________________
Infant Enrollment Intake Form
Social and Emotional development
Has your child been in child care before?
Yes
No
Does your child have a regular routine when at home?______________________________________________
__________________________________________________________________________________________
Is there anything we should know about your child's play with other children, by themselves, any concerns?
__________________________________________________________________________________________
__________________________________________________________________________________________
What kinds of activities does your child enjoy? Are there activities your child avoids?
__________________________________________________________________________________________
Does your child have any siblings? ____________________________________________________________
Does your family have any pets? _______________________________________________________________
Who else lives in your house? _________________________________________________________________
What soothes your child? _____________________________________________________________________
__________________________________________________________________________________________
What frightens your child? ____________________________________________________________________
__________________________________________________________________________________________
Does your child have any favorite songs or games that comfort them? _________________________________
__________________________________________________________________________________________
What concerns do you have about leaving your child in care? ________________________________________
__________________________________________________________________________________________
Do you have any suggestions that will help ease your child’s transition into care? ________________________
__________________________________________________________________________________________
What are your expectations or hopes for your child at our child care center? _____________________________
__________________________________________________________________________________________
What are your expectations for the Children's Center and Center staff members?
__________________________________________________________________________________________
__________________________________________________________________________________________
Is there anything regarding your family, extended family or child that you would like to share with us
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

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