Printable Daycare Form – Fill Out and Use This PDF

Date of Discharge ______________

Reason for Discharge: _________________________________________________________________

____________________________________________________________________________________

Child's full name ______________________________Date of Birth ______________________________

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:

_________________________________________ __________________________________________

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 __________

TRANSPORTATION PLAN / AUTHORIZED PICK- UP

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 ____________________

If applicable: Name of School Child Attends: ________________________________________________

□Copies of any custody agreements, court orders, restraining orders (if applicable)

Notes:

____________________________________________________________________________________

____________________________________________________________________________________

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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? _________________________________________________________________

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.

________________________________________________________________________________________

________________________________________________________________________________________

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Is there anything else we should know about your child?___________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Permissions (for each child enrolled)

General Permission-(Basic Transport) (Parents should not sign this permission unless specific places where your child is allowed to go are listed by your educator.) By signing this form, I am allowing my child to be taken off the child care premises.

I, hereby give __________________________________ permission to take my child ________________

(educator/assistant)

off the premises of the family child care home for the following excursions: (specific places your child is

allowed to go): _______________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

using the following forms of transportation: _________________________________________________

____________________________________________________________________________________

I do not want my child to be taken off the child care premises.

Permission - (Transport to Medical Facility and Receive Emergency Medical Treatment)

Medical Emergency Treatment (Department of Early Education and Care recommends checking with your local hospital about the acceptability of this statement)

I, hereby give __________________________________ permission to administer basic first aid and/or

(educator/assistant)

CPR to my child ______________________________, and/or take my child to a hospital for medical

treatment when I cannot be reached or when delay would be dangerous to my child's health.

Topical Medication/Ointments (Please list only those medications/ointments which you will allow the educator(s) to administer to your child's skin): Ex: sunscreen, insect repellent (bug spray), diapering ointment.

____________________________________________________________________________________

____________________________________________________________________________________

Emergency Card Information

REMINDER : This emergency card information is for the educator’s first aid kit. The educator(s) must take first aid materials when leaving the child care premises.

Child's Name:____________________________ Date of Birth:__________________________________

Child's Home Address:_________________________________________________________________

_________________________________________ Phone: ____________________________________

Instructions to Reach Parent or Guardian

1.__________________________________________________________________________________

(Name, Address, Home and Cell Phone #)

2.__________________________________________________________________________________

(Name, Address, Home and Cell Phone #)

Contact Information for Physician or Health Care Professional

1._________________________________________________________________________________

(Physician’s Name, Address, Phone #)

Emergency Contact Person(s)

1._________________________________________________________________________________

(Name, Address, Home and Cell Phone #)

2._________________________________________________________________________________

(Name, Address, Home and Cell Phone #)

Emergency Medical Treatment

I hereby give ____________________________________________________________ permission to

(Name of educator/assistant)

administer basic first aid and/or CPR to my child _____________________________________________

(Name)

and/or take my child _______________________________________, to a hospital for medical treatment

(Name)

when I cannot be reached or when delay would be dangerous to my child's health.

Subscriber's Name:____________________________________________________________________

Type of Insurance:_____________________________________________________________________

Policy Number:_______________________________________________________________________

[ ] Copy of insurance card

Other pertinent medical information:_______________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Dear Physician: __________________________________________________________________

(Child's Name)

is enrolled in a family child care home which is licensed by the Department of Early Education and Care. The Department of Early Education and Care’s regulations require at the time of admission a written statement from a physician as evidence of each child's annual physical examination, immunizations and lead screening in accordance with Department of Public Health's recommended schedules. A prompt response is appreciated.

Evidence of a physical exam is valid for one (1) year from the date the child was examined and must be renewed annually thereafter.

IDENTIFICATION

Name of Child: ______________________________________ Date of Birth: _____________________

Address: ________________________________________________ Phone # ____________________

Name of Parents: _____________________________________________________________________

Address: ____________________________________________________________________________

Date of Examination of Child: ___________________________________________________________

What is your opinion concerning the child's general health and appearance:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

(*At least one (1) time between ages 9-12 months; Annually-Ages 2 & 3; at Age 4 if High Risk for Lead Poisoning)

If Yes, date screened: _______________

Does this child have any disabilities or chronic medical problems (allergies, limited vision, etc.) which require special consideration or care by the child care educator? If so, please detail below:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Physician's Signature: _______________________________________Date: ______________

Comments: __________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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Please return this form and the child’s immunization record to: