Child Care Registration Form

Last Name:

First Name Middle Name:

Nickname:

Birth Date: Start Date:

NAMES OF SIBLINGS & BIRTH DATES:

PARENTS OR GUARDIANS

(1) Last Name: First Name:

Relationship to Child:

Address:

City: Postal Code:

Best Phone # to be reached during the day: Can you receive text msgs? Emails? Email address:

Employer:

(2) Last Name: First Name:

Relationship to Child:

Address:

City: Postal Code:

Best Phone # to be reached during the day: Can you receive text msgs? Emails? Email address:

Employer:

OTHER EMERGENCY CONTACTS

Name: Relationship to Child:

Home Phone: Work or Cell Phone:

Name: Relationship to Child:

Home Phone: Work or Cell Phone:

AUTHORIZATION FOR PICKUP

Your child will only be released to an authorized person listed on this form (parent/guardian and/or emergency contact). In case of an emergency or an unforeseen circumstance, please indicate the name, address and phone number of any other person(s) who you authorize to pickup your child on your behalf. Name Address Phone

. . .

. . .

A parent/guardian's verbal authorization for pickup must be received before your child will be released to anyone not listed here. If not received, and we cannot notify you by phone, your child will not be released.

Indicate days of the week and times your child will attend New Creations: ____Monday from ____ to _____ ____Tuesday from ____ to _____ ____Wednesday from ____ to _____ ____Thursday from ____ to _____ ____Friday from ____ to _____

MEDICAL INFORMATION

Doctor Office Phone

Address

City: Postal Code

Medical Ins. # Child's Personal ID#:

Allergies:

Medical Needs:

Medication:

IMMUNIZATION: Please include a copy of your child’s current immunizations with this registration form. If you do not have the records, a copy can be obtained from your local clinic.

EMERGENCY CONSENT:

It is our policy to notify a parent when a child is ill or needs medical attention. Occasionally, we cannot contact a parent and we need to get immediate help for the child. Our procedure is to take the child to the nearest emergency service.

Please sign below so that we can take appropriate action on behalf of your child.

I HEREBY GIVE MY/OUR CONSENT FOR MY/OUR CHILD ______________________________ WHEN ILL/INJURED TO BE TAKEN TO THE NEAREST EMERGENCY CENTER BY THE STAFF OF NEW CREATIONS CHILD CARE AND LEARNING CENTER WHEN I/WE CANNOT BE CONTACTED. I CONSENT TO AN AMBULANCE BEING CALLED TO TRANSPORT THE CHILD, IF NECESSARY. I FURTHER AGREE TO PAY ALL COSTS INCURRED FOR TRANSPORT.

. .

Parent/Guardian Signature Parent/Guardian Signature

. .

Date Date

*Please continue registration form to describe specific information about your child.

EATING PATTERNS

IS CHILD USUALLY HUNGARY AT MEAL TIME? ________ BETWEEN MEALS? _________

WHAT ARE HIS/HER FAVORITE FOODS? _________________________________________

WHAT FOODS ARE REFUSED? _________________________________________________

ANY EATING PROBLEMS? _____________________________________________________

ANY FOOD ALLERGIES? _______________________________________________________

DOES CHILD EAT WITH A SPOON? _____ FORK? _____ HANDS? _____

IS CHILD LEFT OR RIGHT HANDED? _____________________________________________

OTHER DIETARY RESTRICTIONS? ______________________________________________

____________________________________________________________________________

TOILET PATTERNS

CAN YOUR CHILD BE RELIED UPON TO INDICATE TOILETING WISHES? _______________

WHAT WORD IS USED FOR URINATIONS? __________ BOWEL MOVEMENT? ___________

DOES THE CHILD NEED TO GO MORE FREQUENTLY THAN USUSAL FOR AGE? ________

IS HE/SHE FRIGHTENED OF THE BATHROOM? ____________________________________

DOES HE/SHE HAVE ACCIDENTS? __________ HOW DOES HE/SHE REACT? __________

DOES THE CHILD NEED HELP WITH TOILETING? __________________________________

DOES THE CHILD WET HIS/HER BED AT NIGHT? ___________HOW OFTEN? ___________

HEALTH HISTORY OF CHILD

WHAT PAST ILLNESS HAS CHILD HAD:

____ CHICKEN POX ____ SCARLET FEVER ____ DIABETES ____ MEASELS ____MUMPS

____ HIV ____ AIDS ____ HEPATITIS A ____ HEPATITIS b ____ OTHER (______________)

DOES YOUR CHILD HAVE FREQUENT COLDS? ____ EAR ACHES? ____

SORE THROAT ____ STOMACH ACHES? ____

DOES HE/SHE VOMIT EASILY? ____ RUN HIGH FEVERS EASILY? ____HAS YOUR CHILD HAD ANY SERIOUS ACCIDENTS? ____ EXPLAIN _____________________________________________

ALLERGIES? ____ HOW DOES IT MANIFEST ITSELF? ____ ASTHMA ____ HAY FEVER

____ HIVES ____ OTHER (_____________________) ALLERGY CAUSED BY _____________

HAS YOUR CHILD EVER BEEN:

HOSPITALIZED? ____________________________ EXPLAIN _______________________

HAS YOUR CHILD EVER BEEN TO A DENTIST? _____________________________________

DOES YOUR CHILD HAVE ANY DISABILITIES? ________ EXPLAIN _________________

PLEASE GIVE A STATEMENT OF YOUR EVALUATION OF YOUR CHILD’S OVERALL HEALTH.

____________________________________________________________________________

NAPPING

DOES YOUR CHILD TAKE NAPS? ____________ (FROM ______ TO _________)

IF NOT, WHAT DO YOU WANT YOUR CHILD TO DO DURING REST TIME?

DOES YOUR CHILD HAVE A SPECIAL TOY OR BLANKET TO SLEEP WITH?

DOES YOUR CHILD SLEEP IN A CRIB OR BED AT HOME?

SOCIAL RELATIONSHIPS

WHAT CAN WE DO SO THAT YOUR CHILD WILL ADJUST EASILY TO NEW CREATIONS?

WHAT MAKES YOUR CHILD SMILE ALMOST EVERY TIME THIS IS DONE OR MENTIONED?

WHAT MAKES YOUR CHILD ANGRY OR UPSET?

IS YOUR CHILD FRIGHTENED BY SUCH THINGS AS: ANIMALS, ROUGH CHILDREN, LOUD NOICES, THE DARK, OR STORMS?

FAVORITE TOYS AND ACTIVITIES AT HOME:

DOES YOUR CHILD LIKE TO BE READ TO? LISTEN TO MUSIC?

GENERAL INFORMATION

DOES YOUR CHILD HAVE ANY OTHER PROBLEMS WE SHOULD BE AWARE OF?

____________________________________________________________________________

BRIEFLY DESCRIBE YOUR CHILD (physical appearance, personality, abilities, etc.)

____________________________________________________________________________

To be filled out by New Creations:

1. Parent Conference Date #1:

Summary:

2. Parent Conference Date #2:

Summary: