| Little Steps Childcare Baby Enrollment Form Childs Name_________________________________ D.O.B._______________ Health Card Number____________________ Is your baby: Breastfed Bottle-Fed How Often?________________________________________ (If breastfed, you may feed your baby at daycare if you choose) Number of bottles I will be giving the baby each day?(estimate)___________________________ How many ounces?_________ Does he/she drink it Warm____ Cold____ How do you heat the bottle? Stove____ Crock pot____ Other____________________________ Name of formula______________________________________________________________ Any special feeding instructions?__________________________________________________________ Does your baby need to stop feeding to burp, be changed, etc.? Yes___ No___ If yes, please explain______________________________________________________________ Is your baby on a schedule? Yes___ No___ If yes, please write schedule:____________________________________________________________ ____________________________________________________________________ Does baby drink juice, eat cereal, or any other solid food?(please specify)______________________________________________________________ ____________________________________________________________________ Do you allow your baby to have a pacifier? Yes___ No___ If so, when? Bedtime___ When Fussy___ Anytime___ Has your baby been exposed to other children often? Yes___ No___ Please specify_______________________________________________________________ Are any medications given regularly? Yes___ No___ Do you have a reliable backup provider for times when I am closed due to illness, vacation, holiday, your child is ill, etc? Yes___ No___ What time does your baby awaken? ____________________________________________________________________ What time does your baby go to sleep at night? ____________________________________________________________________ Does your baby sleep through the night? ____________________________________________________________________ Does your child have any security objects such as a blanket, pacifier, toy, etc. that helps him/her when upset? Yes___ No____ If so what? ____________________________________________________________________ How is your child most easily settled when upset or afraid? ____________________________________________________________________ ____________________________________________________________________ Does he/she enjoy being rocked or read/sung to? Yes___ No___ May I take your baby for a walk? Yes___ No___ Parent/Guardian Signature_________________________________________________________ Parent/Guardian Signature_________________________________________________________ Date________________________ Please include a written schedule for your child. |
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