| Name: | |
| Nickname used: | |
| Date of Birth: | |
| Other children in family (list relation and ages) | |
| Do you have a back-up provider if caregiver or child is ill? (_)YES (_)NO | |
| Has your child had previous daycare experience? (_)YES (_)NO | |
| List 5 words to describe your child's personality | |
| 1) | |
| 2) | |
| 3) | |
| 4) | |
| 5) | |
| Is your child comfortable with other adults? (_)YES (_)NO | |
| Is your child comfortable with other children? (_)YES (_)NO | |
| How does your child express his/her feelings?(ie.anger,frustration) | |
| What type of discipline is used at home? | |
| Child's usual dining habits (please circle all that apply): |
| Bottle | Sippy Cup | Regular Cup |
| Highchair | Booster Seat | Chair |
| Uses Fingers | Uses Utensils |
| Favorite Foods: | |
| Strong Dislikes: | |
| Do you have a problem with your child celebrating any holidays? (_)YES (_)NO | |
| If YES, please list | |
| Does your child have any fears? | |
| What is your child's favorite indoor activity? | |
| What is your child's favorite outdoor activity? | |
| What is your child's favorite toy? | |
| Does your child normally nap at home? (_)YES (_)NO | |
| If YES, Please list normal nap schedule: | |
| Does your child have a special doll/toy blanket that they like to nap with? (_)YES (_)NO | |
| Is your child potty trained? (_)YES (_)NO | |
| If YES, what words does your child use for the use of the bathroom? | |
| Does your child have accidents? (_)YES (_)NO | |
| If YES, approximately how often? | |
| What are your expectations of My Home Child Care? | |
| Is there anything else you feel I should know in order for me to better care for your child? | |
Kelly's Home Childcare
www.geocities.com/kellyshomecc
