Mountain Nest

Family Daycare

Getting to Know Your Child

Personal Information

Child’s Full Name: _____________________________________________ Nickname: ______________________

Birthdate: ________________________________________________ Sex: M F U

Hair colour: _____________________________________ Eye colour: ____________________________________

Favourite toy: ___________________________________ Favourite book: ________________________________

Name of siblings, if any, and ages: ________________________________________________________________

Does your family celebrate any cultural or religious holidays? NO YES _________________________

_____________________________________________________________________________________________

Favourite indoor activities: ______________________________________________________________________

Favourite outdoor activities: _____________________________________________________________________

Daycare History:

Has your child had previous experience away from home? NO YES If YES, explain: _______________

_____________________________________________________________________________________________

Is your child nervous to leave you? NO YES If YES, explain: ___________________________________

_____________________________________________________________________________________________

Eating Habits:

Does your child have a special diet? ______________________________________________________________

Are there any foods that should not be served to your child? __________________________________________

Favourite foods? ______________________________________________________________________________

Strong dislikes? _______________________________________________________________________________

Does your child require: Bottle Sippy cup High chair Booster seat

Does your child: Use utensils Eat independently Enjoy eating

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Family Daycare

Sleeping Habits:

Does your child have a regular bedtime schedule? NO YES

What time approximately does your child: Go to bed __________ Wake up __________ Nap time(s) __________

What is the bedtime routine? ____________________________________________________________________

Does your child need a comfort toys/blankets, etc. for sleep? Please specify: ____________________________

_____________________________________________________________________________________________

Does your child have any problems getting to sleep or staying asleep? NO YES: _________________

_____________________________________________________________________________________________

Behaviour:

How would you describe your child’s usual temperament? Active Social Quite

Independent Constructive Demanding Nervous Other:_______________________

Does your child have any fears/anxieties that we should be aware of? __________________________________

_____________________________________________________________________________________________

How do you “reward” and/or “discipline” your child? _________________________________________________

Is there anything else about your child you feel I should know? ________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

___________________________________________________ ________________________________
Signature of Parent/Guardian Date

___________________________________________________ ________________________________
Signature of Parent/Guardian Date
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Family Daycare
Health, Safety, and Emergency Information
Child’s Full Name: _____________________________________________________________________________

Parent/Guardian:
_____________________________________________ Place of Employment: _____________________________

Home: _________________________ Cell: ___________________________ Work: _________________________

Address : _____________________________________________________________________________________

Is this the child’s primary residence? NO YES

Email Address: ________________________________________________________________________________

Parent/Guardian:
_____________________________________________ Place of Employment: _____________________________

Home: _________________________ Cell: ___________________________ Work: _________________________

Address (if different than above): _________________________________________________________________

Is this the child’s primary residence? (if different than above) NO YES

Email Address: ________________________________________________________________________________

Are there any special instructions concerning custody? NO YES If Yes, attach documents.

Emergency Contacts: Permission must be received by daycare staff before they will release a child to anyone
who is not yet authorized. The following people are authorized to pick up my child from daycare:
1. _________________________________________________ Relationship: ________________________

Home: ________________________ Cell: _______________________ Work: _________________________

2. _________________________________________________ Relationship: ________________________

Home: ________________________ Cell: _______________________ Work: _________________________

3. _________________________________________________ Relationship: ________________________

Home: ________________________ Cell: _______________________ Work: _________________________

Record of any persons NOT permitted access to my child:

1. ____________________________________________________ Relationship: ______________________

2. ____________________________________________________ Relationship: ______________________

3. ____________________________________________________ Relationship: ______________________

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Family Daycare
Medical Information:
Care Card Number: ____________________________________________________________________________

Family Doctor: __________________________________________ Phone Number: ________________________

Details for any other agencies or professionals working with our child and their role: ______________________

_____________________________________________________________________________________________

Does your child have any known health concerns or depressed immune system? _________________________

_____________________________________________________________________________________________

Does your child suffer from any of the following on a regular basis? Nosebleeds Headaches Sore throat

Colds Stomach-aches Runny nose Seasonal allergies Ear aches Other: _______________

Does your child take any mediations the daycare should know about? __________________________________

List any allergies your child has: __________________________________________________________________

List any communicable diseases your child has had, such as chickenpox, mumps, or hepatitis: ______________

_____________________________________________________________________________________________
Immunization:
Please check the immunizations your child has received or attach an immunization record:

Immunizations Yes No
2 months: Diphtheria, Pertussis, Tetanus, Polio, Haemophilus Influenza Type B, Hepatitis B,
Pneumococcal conjugate, Meningococcal C Conjugate, Rotavirus
4 months: Diphtheria, Pertussis, Tetanus, Polio, Haemophilus Influenza Type B, Hepatitis B,
Pneumococcal conjugate, Rotavirus
6 months: Diphtheria, Pertussis, Tetanus, Polio, Haemophilus Influenza Type B, Hepatitis B,
Hepatitis A
12 months: Measles, Mumps, Rubella, Varicella, Meningococcal C Conjugate, Pneumococcal
Conjugate
18 months: Diphtheria, Pertussis, Tetanus, Polio, Haemophilus Influenza Type B, Hepatitis A

I authorize Mountain Nest Family Daycare to call emergency services in the case my child has an accident or
illness of a life-threatening nature. I understand that I will be responsible for all costs involved.

I agree to abide by the Illness/Wellness policy. I will notify the child care provider if my child has come in
contact with any communicable disease or head lice.

I will sign a consent form if I need the care provider to administer any medications to my child.

________________________________________________________ ____________________________
Signature of Parent/Guardian Date
________________________________________________________ ____________________________
Signature of Parent/Guardian Date
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Family Daycare
Parent/Guardian – Provider Child Care Agreement
Office Use Only: ____________________________________________ Date of Enrollment

___________________________________________ Date of Termination

Parties Involved:
This agreement is intended to serve as a guideline for childcare between Mountain Nest Family Daycare and

__________________________________________________________________________ concerning the care of

parent(s)/guardian(s)

_________________________________________________.
child

Standard Rates and Payment Policies:

Standard rate is $45.00/day or $25/half-day. Any time over and above the agreed hours of care, will be
charged as overtime, at the rate of $20 per half hour.

Payment is due before the first day of care for the agreed pay period. Late payment will result in the immediate
termination without notice from the provider. For special circumstances, make prior alternative arrangements.

If my child does not come to daycare due to holidays or illness, I understand that I am still responsible for full
payment unless an alternative arrangement has been made. I am not required to pay for the statutory holidays.

The hours and days needed for daycare are:

____________ ____________ ____________ ____________ ____________

Monday Tuesday Wednesday Thursday Friday

I will pay $45.00 per day, to be paid: daily weekly bi-weekly bi-monthly monthly

I agree to notify the provider by 8:00 am if my child will be absent for the day. Parents/Guardians will be
charged the standard rate for any days their child misses, unless alternatives arrangements have been made.

If the provider is unable to provide care due to illness or emergency, they will inform the parents/guardians by
8:00 am the morning of the absence. Parents/Guardians are responsible for finding alternative care for the
duration of the absence. The provider will not charge daycare fee for days the center is unexpectedly closed.

Termination/Changes Procedure:
The first two weeks are an adjustment period and either party may terminate this agreement during that time if
the arrangement turns out to be unsatisfactory. Afterwards, 2-weeks’ notice is required to terminate this
agreement. If 2-weeks’ notice is not given, any payment already made will not be refunded. This contract will
be reviewed yearly.

Changes to the contract desired by provider or parent/guardian, must be made in writing and acknowledge in
writing at least 2 weeks before changes take effect. A new contract will be signed that reflect the changes.
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Family Daycare
Updates:
Parents/guardians are kept informed and engaged with their child’s experience and development while at the
center. Please choose how you would like to stay informed from the following options:
o Verbal updates at pick up/drop off times
o Text message with pictures
o Monthly written reports

Extra Provisions:
I agree to supply the following relevant items each day for the use of my child:
• morning snack, lunch, and afternoon snack • diapers, wipes, and diaper cream
• formula/breast milk • sunscreen, fly repellant
• 2 spare changes of clothing • naptime comfort toy
• sufficient outdoor clothing for the weather

Additional Permission:
Consent for Safe Release of Child:
I agree to deliver and pick up my child directly to/from the care provider. I will not let me child go into the
center by themselves or take my child from the yard without first speaking to the care provider.
YES / NO
Consent for Photographs:
I give my consent for photographs of my child to be taken by staff. I understand that these photographs may be
posted inside the center or used for identification purposes.
YES / NO
I give permission for photographs of my child to be taken by staff and posted on the Mountain Nest Family
Daycare Facebook page, local newspaper, or promotional material.
YES / NO
Consent for Neighbourhood Walks:
I give permission for my child to take neighbourhood walks around Raspberry and Pass Creek Park. I
understand that these walks may not be planned ahead of time and that proper supervision will always be
provided.
YES / NO
Consent to use sunscreen/insect repellent:
I give permission for Mountain Nest Family Daycare to apply sunscreen and/or insect repellent on my child.
YES / NO
By signing this contract, all parties agree to all of the above terms and policies, including financial
responsibility for the child care provided.

______________________________________________ ____________________________________
Parent/Guardian’s signature date
______________________________________________ ____________________________________
Parent/Guardian’s signature date
______________________________________________ ____________________________________
Care Provider’s signature date