Beruflich Dokumente
Kultur Dokumente
ChildsName:_______________________________________Date:______________________
Childsage:_______________________________
ChildsBirthday:________________________Nickname:____________________
Address:_______________________________________________________________________
_____________________________________________________________________________
Parent/GuardianContactInfo:
Momsname:________________________________________________
Dadsname:_________________________________________________
Guardianname:______________________________________________
(Mother)HomePhone:____________________________________
(Mother)WorkPhone:____________________________________
(Mothers)CellPhone:____________________________________
(Father)HomePhone:_____________________________________
(Father)WorkPhone:_____________________________________
(Fathers)CellPhone:_____________________________________
EmergencyContactInformation
EmergencyContactPerson#1:_____________________________
Relationshiptochild:_____________________________________
Contactsphone:_________________________________________
EmergencyContactPerson#2:______________________________
Relationshiptochild:______________________________________
Contactsphone:__________________________________________
Doyouhaveabackupcareprovider(circleone)?YesorNo
Ifyes,pleasegivenameandcontactnumber:
_______________________________________________________________
Scheduling
Beginningdateofenrollment:_____________________________
Pleaseselectprogram:
FulltimePreschoolProgram(MondaythroughFriday8:30am5:30pm)
IncludesFreshOrganicLunch,andhealthysnacksinthemorningandafternoon
ModifiedPreschoolProgram(pleasespecifydropoffandpickuptimesbelow,andnote,
thereareadditionalfeesforearlyandlatepickups)
ModifiedProgramHours:
Monday____________________
Tuesday____________________
Wednesday______________________
Thursday________________________
Friday______________________
Timeyouplantodropoffyourchild________
Timeyouplantopickupyourchild_________
PaymentInformation
PaymentSchedule(selectone):
Weekly,eachFriday=$330/week
Monthly,onthelastdayofthemonth=$1,200/month(discount10%off)
Biannually(inSeptemberandFebruary)=$6,500everysixmonths(18%off)
Paymentmethod
Personalcheck
Paypal
Cash
YourChildsHealth
CHILD'SHEALTHRECORD:(Acopyofacurrentphysicalwillbeneeded)
Generalstateofhealth:
________________________________________________________________________
________________________________________________________________________
Doctorsname_____________________________________________________
Doctorsphonenumber_______________________________________________
Dentistsname_____________________________________________________
Dentistsnumber___________________________________________________
Areyourchild'simmunizationsuptodate?_________(Asstatedinourhandbook,werespecta
parentsrighttochoosewhethertheyvaccinatetheirchild,weaskforthisinformationonlyasa
matterofrecord)
Doesyourchildhaveanyknownallergies(includingfoodallergies)?
__________________________________________________________________________
Areyouconcernedthatyourchildmaybepronetoanytypeofallergies?___________
Describe:
______________________________________________________________________________
Arethereanydietaryrestrictionsorfoodsyourchildshouldavoid?Pleaseexplain.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Doesyourchildhaveanymedicalconditionswhichweshouldbemadeawareof?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Hasyourchildhadthefollowingchildhoodillnesses?(pleaseselect)
Doesyourchildhadtroublewithanyofthe
following?
Constipation
Convulsions
Diarrhea
FaintingSpells
FrequentColds
FrequentEarInfections
FrequentSoreThroats
Lice
Ringworm
SkinRash
Soiling
StomachUpsets
UrinaryProblem
Soiling/wettingthebed
Phobias
Anxiety
Hasyourchildhadanyofthesechildhood
diseases?
Asthma
Bronchitis
Chickenpox
Mumps
Measles
Polio
ScarletFever
Tuberculosis
WhoopingCough
Hepatitis
Diabetes
Obesity
GermanMeasles
Doesyourchildhaveanyspeech,hearingorvisualproblems?
__________________________________________________________________________
Wouldtherebeanyrestrictionstoplayoractivities?Pleaseexplain.
__________________________________________________________________________
AboutYourChild
Hasyourchildeverbeeninchildcare/Preschoolawayfromhomebefore?_________
Whattype(center,familydaycare,grandmaetc.)?_________________________________
Wasitapositiveexperience?___________________________________________________
WhatisthemostimportantthingyouarelookingforinaPreschool?
___________________________________________________________________________
Howdoesyourchildfeelaboutdaycareandbeingleftbyhis/hermommy/daddy?
___________________________________________________________________________
Arethereanyrecenttraumatic/lifechangingsituationsthechildhasbeenexposedtosuchasa
deathinthefamily,divorce,newsiblingetc.?
_____________________________________________________________________________
Whatisyournormalmethodofdiscipline?
_____________________________________________________________________________
Whatisyourchild'stemperament?Ishe/sheeasygoing,calm,bright,demanding,aggressive,
playful,silly,energetic,cooperative,introverted,extrovertedetc.?
______________________________________________________________________________
______________________________________________________________________________
Whatis(are)yourchild'sfavoritefood(s)?
______________________________________________________________________________
______________________________________________________________________________
Whatfood(s)doesyourchilddislike?_______________________________________________
______________________________________________________________________________
Doyouencouragetryingnewfoodsathome?YesorNo
Isyourchildpottytrained?YesorNo
Howdoesyourchildindicatehis/herneedtousethebathroom?
______________________________________________________________________________
Whatwordsdoesyourchildusefor:Bowelmovements__________urination___________
Whattimedoesyourchildwakeup?___________________________________________
Whattimedoesyourchildgotosleepatnight?__________________________________
Dotheysleepthroughthenight?______________________________________________
Doesyourchildsleepinabedorcrib,other?____________________________________
Arethereanysiblings?Pleasenamethemandspecifyagesandgender.
Name_____________________age__________________gender_______________
Name______________________age__________________gender_______________
Name______________________age__________________gender_______________
Hasyourchildhadexperienceplayingwithotherchildren?__________________________
__________________________________________________________________________
Whatlanguagesarespokenathome?
________________________________________________________________________
Doesyourchildhaveanysecurityobjectssuchasablanket,soother,bottle,toyetc.?
_________________________________________________________________________
Whatareyourchild'sfavoriteactivities,toys,books,orgames?
_________________________________________________________________________
Arethereanyotherinformation/concernsaboutyourchildyouwouldlikeustoknowabout?
_________________________________________________________________________