Starchild Enroll Form

Enrollment Form

    Date :
    The Entrant :

 

Child's Name Nickname
Child's Birthday Child's Age
Home Address

 

Contact Info:
  Mom Dad
Name
Home Phone
Work Phone
Cell Phone
Emergency Contact Person
Contact's Phone

 

Service Info  
Times you plan to drop your child off
Times you plan to pick up your child

 

Your Child's Health
CHILD'S HEALTH RECORD : (A copy of your child's immunizations and current physical will be needed)
General state of health :
Doctor's Name :
Doctor's Phone Number :
Are your child's immunizations up to date? 
Does your child have any known allergies?
Does your child have any medical conditions which we should be made aware of?

 

(Please attach a copy of immunizations. This should include the signature of nurse or doctor who administered medications.)
Has your child had the following common childhood illnesses? please ☑
Does your child have any problems with any of these? Has your child had any of these diseases?
Does your child have any speech, hearing of visual problems?
Would there be any restrictions to play or activities? If yes, please explain.

 

About your child at Daycare
Has your child ever been in child care before?
If yes, was it positive experience?
Why are you looking for child care?
How does your child feel about daycare and being left by his/her mommy/daddy?
Are there any recent troumatic situations the child has been exposed to such as a death in the family, divorce, new sibling, etc?
What is your normal method of discipline?
What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc.
Are there any food restrictions?
What is your child's favourite food?
What food does your child dislike?
Can your child be relied upon to indicate bathroom wishes?
What time does your child awaken?

 

Are there any siblings? Please name them and specify ages and gender.
Name Age Gender
Name Age Gender
Name Age Gender

 

Has your child had experience playing with other children?
What language(s) are spoken at home?
Does your child have any security objects such as a blanket, soother, bottle, toy, etc?
What are your child's favorite activities, toys, books, or games?
Are there any other comments of information you would like to let me know about?
Any specific concerns?