4455 South Brandon Street

Primm ABC Child Care/Preschool & E.C.E.A.P.

4455 South Brandon Street

Seattle, Washington 98118

Office (206) 723-2038 Fax (206) 760-1704

www.primmabccenter.net

Child Care Registration

Date Enrolled: ______Date Withdrawn:______Birthdate:______Age:______Sex:______

Name: ______

Last Name First Middle Nickname

Address: ______Home Phone: ______

Street City Zip

Check one: ______One parent household, employed or in training/school

______Two parent household, both parents working or in training

Mother Father

Name:______Name:______

Home Address:______Home Address:______

Name of Employer:______Name of Employer:______

Employer Address:______Employer Address:______

______

Work#:______Cell#: ______Work #:______Cell#:______email:______email______

Monthly Income: $______Monthly Income: $______

Days & Hours of Employment______Days & Hours of Employment______

Names & Ages of other children in home ______

If child currently in childcare, Name of center/provider:______Phone:______

Names, addresses, phone numbers of persons authorized to take child(ren) from Center:

Name:______Address:______Phone:______

EMERGENCY: In case of an emergency, if parents cannot be reached, contact:

Name______Relationship ______

Address______Zip______Phone______

Hours when care is needed: ______to ______

Circle days of the week when care is needed: Monday Tuesday Wednesday Thursday Friday

Child’s Name______Date of Birth______

Developmental, Social and Health History

We want to provide your child with the best care possible. Please help us get to know your child by filling out this questionnaire. Thank You!

Daily Living Routines

Sleeping

· Please describe your child’s usual bedtime routine.______

______

· Does your child sleep well? ______About how long each night?______

· What is your child’s usual bedtime?______Does your child nap?______

· How many times per day?______How long? ______

· Does your child sleep with a special blanket or toy?______

· Does your child go to bed with a pacifier?______Bottle?______

· Does your child have sleep disturbances – nightmares, sleepwalking, waking at night or difficulty going to sleep? Please circle Yes No

If Yes, please describe______

______

· Do you have any concerns about your child’s sleep habits?______

______

Eating

· Would you say your child generally enjoys eating?______

· What are some of your child’s favorite foods?______

· Is your child on any special diet? (Please note: State law requires a special form signed by your child’s health provider if your child has any diet modifications.)

______

· Does your child have any allergies? ______If so, what______

· Are there any foods special to your home or culture that you would like us to offer?

______

· What does your child use to drink? __ bottle __ tippy cup __ regular cup

· If your child uses a bottle, what type of nipple?______

· How does your child eat? __ hands __ spoon __ fork

· Do you have any concerns or questions about your child’s eating? ______

______

Child’s Name______Date of Birth______

· What kinds of activities does your child enjoy? (Games, TV, outdoor play, watching others, puzzles, books, playing with model animals, cars, people, bike riding, dancing, music, sports)

______

· How would you describe your child’s temperament and personality? (Examples: quiet, shy, moody, intense, cheerful, adaptable, easygoing, fiery, assertive, independent, thoughtful, impulsive, careful)

______

· What is the best way to comfort your child? ______

______

· How do you guide/teach your child correct behavior? ______

______

· Does your child fear certain things? (For example, loud noises, dogs, the dark, clown) ______

______

· Upsetting events, losses (such as separation, divorce or death in the family) and change can affect a child’s behavior. We need to be aware of any significant changes in your child’s life so we can understand and help her/him cope and adjust. Has anything happened that may affect your child’s behavior?______. If yes, please explain______

______

· Who lives at home with your child?______

· Do you have any questions or concerns about your child’s social and emotional development or behavior? _____. If yes, please explain. ______

· What can we do to ease your child’s adjustment to child care?______

______

· What would you like to see your child gain/learn at our child care center? ______

______

· Do you have any questions about our health and safety policies, this questionnaire or anything else? ______

______

Child’s Name______Date of Birth______

Morning Routine

· Does your child eat breakfast before coming to child care? ___ Yes ___ No

· Can your child dress him/herself?______

· Do you have a morning routine that helps your child prepare for child care?______

______(Note: We encourage you to establish a predicable routine of saying goodbye to ease separation. We would be happy to offer some useful suggestions.)

Toileting

· Does your child use diapers? __ Yes __ No

If Yes, what kind? __ Disposable __ cloth

If cloth, what type of cover? __ Plastic pants __ diaper wraps

· Is your child potty trained?______

· Does your child use a potty or the toilet? ______Does your child use training pants?______

· How does your child let you know that it’s time “to go”?______

· Families tend to use a variety of words to describe bathroom activities. What words does your child use for

urine ______, bowel movement ______,

· genital area ______

· Do you have any questions or concerns about your child’s toilet habits? ______

______

(Please note: We are required by State law to send all dirty cotton diapers home unless we have diaper service. We are not permitted to launder diapers on the premises).

Physical Health

Your child’s regular health care provider:

Name:______

Address:______

Phone Number:______Last physical exam:______

Medications:______

Your child’s dentist:

Name:______

Address:______

Phone Number:______Last dental exam:______

______

Signature of Parent