| Little Steps Childcare Child Enrollment Form Enrollment Form Entry Date________________ Childs Name___________________________________ Age________ D.O.B._______________ Sex_______ Health Card #_____________ Parents Names____________________________________________ Mothers Work Place________________________________________ Work Phone#__________________ Fathers Work Place ________________________________________ Work Phone#_________________ Home Address_____________________________________________ Home Phone#___________________ Cell#______________________ Pager#______________________ Childs Doctor___________________________ Phone#____________________ Emergency Contacts: Name____________________ Relationship________________ Phone#____________ Name____________________ Relationship________________ Phone#____________ Name____________________ Relationship________________ Phone#____________ Questionnaire: 1. What do you expect from me for your child care?____________________________ ____________________________________________________________________ 2. Does your child have a nickname? _______________________________________ 3. What words does your child use regarding the bathroom?______________________ 4. Is your child self-sufficient in the bathroom? Yes No what areas does he/she require assistance?__________________________________ 5. Does your child have any fears or anxieties?________________________________ 6. Does you child have any allergies?________________________________________ 7. Special instructions incase of a allergic reaction______________________________ 8. Does your child have any recurrent medical problems? Yes No 9. Please describe your Childs waking/sleeping habits___________________________ _____________________________________________________________________ 10. What is your Childs favorite food?_______________________________________ 11. What food does your child dislike?_______________________________________ 12. What is your Childs favorite toy(s)?_______________________________________ 13. List communicable diseases your child has had (circle those that apply) Chicken Pox Measles Mumps Other_____________________________________ 14. Is your child prone to: (circle those that apply) Upset Stomach Colds Headaches Sore Throats Ear Aches 15. Are there any indications of vision or hearing problems? Yes No 16. 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 17. Is your child potty trained? Yes No 18. Does your child need regular medication for any health problems? Yes No 19. May I take your child(ren) for walks? Yes No Parent/Guardian Signature____________________________________ Parent/Guardian Signature____________________________________ Date___________________ |
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