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Leslie's Home Daycare |
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About My Child |
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Child’s Name:_________________________________ Birthdate:____________________________________ Home Phone:_________________________________ Address:_____________________________________ ____________________________________ ____________________________________ Nickname:____________________________________ Mother’s name:________________________________ Work phone:__________________________________ Cell Phone:___________________________________ Father’s name:_________________________________ Work phone:__________________________________ Cell phone:___________________________________ Parents e-mail address:___________________________ Emergency Contacts 1.____________________Phone #________________ 2.____________________Phone #________________ 3.____________________Phone #________________ 4.____________________Phone #________________ Persons Authorized to pick up child ( besides parents) 1.__________________________________________ 2.__________________________________________ 3.__________________________________________ 4.__________________________________________ I must be introduced to prior to pick-up......... or children will NOT be allowed to leave. Emergency Information Child’s Doctor;________________Phone #__________ Insurance company;____________policy #___________ Health Card #__________________________________ Child’s Health Record General state of health:___________________________ Are your child’s immunizations up to date?____________ Please submit a copy of immunization record. Does your child have any known allergies?_____________ _____________________________________________ _____________________________________________ Are you concerned that your child may be prone to any type of allergies?________________________________ Describe:______________________________________ __________________________________________ Does your child have any medical conditions which I should be made aware of ? ______________________________ _____________________________________________ Has your child had the following common childhood illnesses? Chicken pox:___________ Measles:______________ Whooping cough:_______ German measels:_______ Mumps:_______________ other:________________ Is your child prone to: Ear Infections:____________ Headaches:______________ Stomach upsets:__________ Colds:__________________ Sore throats:_____________ Does your child have any speech, hearing or visual problems? _____________________________________________ _____________________________________________ Has your child ever been tested for the above? _____________________________________________ Has your child ever had any surgeries? _____________________________________________ _____________________________________________ _____________________________________________ My Child Favorite toys, activities etc.....:______________________ Favorite foods and snacks:________________________ How do you discipline:____________________________ Does your child nap:_____________________________ How long:_____________________________________ Is your child potty trained ?________________________ How does your child let you know that they have to go potty ? ____________________________________________ Any other things that I should know about: ___________________________________________ ___________________________________________ Has your child been in Daycare Before?_______________ _____________________________________________ With whom:____________________________________ Reason for Leaving:_____________________________ _____________________________________________ _____________________________________________ _____________________________________________ Can I call this daycare?___________________________ Contact person:________________________________ phone # :_____________________________________ Thank you for your time. The more I know about your child, the better. Every bit of information helps all of us. Emergency Medical Treatment Authorization In the event of an emergency when we are not available, we authorize the administration of any medical procedures deemed necessary by my doctor, or if unavailable, by any other doctor selected by my caregiver. DATE:_____________________________ Parent’s Signature:__________________________ Parent’s Signature:__________________________ My Caregiver’s name is:______________________ My Caregiver’s address is:____________________ ______________________ ______________________ ______________________ Our Hospital of preference:____________________ Child’s Health Card #. _______________________ to take _____________________ on field trips, day trips and any other outings. Signed______________________Date:_________ Signed______________________Date:_________ I grant permission for Leslie’s Home Daycare to use sunscreen on _____________________________ Signed_____________________Date:_________ Signed_____________________Date:_________ Parents are required to provide the sunscreen, and mark their child’s name on the outside of the bottle. Permission for Photo’s I _____________________________ give permission to Leslie’s Home Daycare, to take photos of ____________________________________ for print. I ______________________________give permission to Leslie’s Home Daycare, to take photos of ________________________________for publish on the Internet. All pictures will be in an album that is password protected. Nobody will be able to access the pictures without the password. Name:___________________________ Date:____________________________ |
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