Child's Name:_____________________________ Nickname:__________________
How would you describe your child's personality?

Has your child been to daycare before? yes/no
Why was care terminated?

Dates attended from _________ to _________
May I use them as a reference? yes/no

Name: _____________________ Telephone: _____________________

Does your child have a regular bed time schedule? yes/no
What should I know about your child's sleeping?

Toy or blanket to fall asleep? yes/no Trouble sleeping? yes/no

Disposition upon waking?

Has or does your child have any known health condition? yes/no

Does your child have any known allergies? yes/no
Explain:

Is your child prone to any ailments (upset stomach, frequent colds, allergies, ear infections, nose bleeds, etc?)

Is there any indication of hearing or vision problems? yes/no
Explain:

What are your child's eating habits? (Frequency, portion)

Does your child have any favorite foods?

Does your child have a special diet?