Child Intake Information

Childs name:__________________ Nickname:__________________

Birth date: _______________
Fathers Name: ___________________ Mothers Name: _________________________

Address: _________________________________________________

Is anyone specifically denied permission to see your child? Yes No

If there is, please name here: ________________________________________

Has your child been in a Day Care Center/In Home Childcare before? Yes No

If so, which one and reason for leaving:_________________________________________________





Does your child have any special health needs I should know about? Yes No
Any Food Allergies? Yes No (more detail to be shared on Allergy and Food Pref. Info Form included in Enrollment Pkg.)
Does your child usually nap? Yes No Current Nap Time Schedule: _________________
Nap Time schedule here is 12:30-2:30

Does your child have any particular fears we can avoid or help with? _________________________









Your childs favorite:
Toys/ games: __________________________________________
Activities:_____________________________________________
Color: ________________Books/ Stories:__________________
____________________________________________________________

Circle some words that describe your child:

Happy Assertive Friendly Moody

Dependent Stubborn Impulsive Attentive

Fearful Quiet Sleepy Good-natured

Shy Independent Fearless Outgoing

Talkative Emotional

Does your child have any nervous habits, and when does he/she show them? _______________

_____________________________________________________________________________

What is your discipline method at home?:____________________________________________

At Michelle Jensens Daycare, I use re-direction, shadowing and reflection time-out as our disci-
pline method. How do you feel about this? *See my Discipline Policy for more detail.
_________________________________________________________________

Is your child fully potty trained? Yes No

Fully potty trained to me means: Routinely Uses toilet under self direction, can remove and replace clothing as necessary,
knows how and does sufficient job at wiping for all eliminations, knows how (soap/ time) and routinely will wash hands after toilet use
(without direction). If they are Potty Ready or you would like help please be sure to submit to me a Potty Train Plan Form

Names and ages of childs siblings: ________________________________

Is there any further information that may be helpful in understanding your child (i.e.: visual/physical/mental
challenges, separated/divorced parents, recent move/death/birth..)