Printable Daycare Form – Fill Out and Use

			*P H O T O OF C H I L D
		FAMILY CHILD CARE	(*Optional)
	Children’s Records must		P L U S
	five (5) years after a child	ENROLLMENT PACKET	P H Y S I C A L
	be maintained for at least	F A C E S H E E T
	has left the program		D E S C R I P T I O N
			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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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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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: _________________________________________________

____________________________________________________________________________________

____________________________________	______________________________________
Parent/Guardian	Signature Date

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

____________________________________	_____________________________________
Parent/Guardian	Signature Date

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.

____________________________________	_____________________________________
Parent/Guardian	Signature Date

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.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________	_____________________________________
Parent/Guardian Signature	Date
	Child’s Name _________________
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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.

_______________________________________	______________________________________
Parent/Guardian	Date
Medical Insurance Information (Optional)

Subscriber's Name:____________________________________________________________________

Type of Insurance:_____________________________________________________________________

Policy Number:_______________________________________________________________________

[ ] Copy of insurance card

Other pertinent medical information:_______________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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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:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Has this child been screened for lead poisoning?

Yes ________ No _________

(*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: __________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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

	_____________________________________
	_____________________________________
	_____________________________________
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