Enrollment Questionaire

ENROLLMENT QUESTIONAIRE

Child’s Name:______Date of Birth ______Gender: ____M ____F

Eating

Is your child on any special diet? _____Vegetarian ____ovo-lacto _____vegan _____ other

Does your child have any food allergies? ______If yes, please describe ______

______

Would you allow us to post the name of your child to our “Allergy Alert” form for staff? _____Yes ____ No

What does your child use to drink?

_____bottle ____ sippy cup ____regular cup ____nursing_____other:______

How often does your child eat?______

Sleeping

Does your child nap? ______How many times per day?______How long?______

Does your child sleep with a special blanket, toy or pacifier? ______Yes______No

Are there specific bedtime routines at home? ______

Toileting

Does your child wear diapers? ______Yes ______NoPull-ups? _____Yes_____No

Is your child FULLY toilet trained? ______Yes _____No

Are there any specific ointments or lotions your family uses: ______

Does your child let you know when they have “to go”? ______

Does your child need regular reminders to use the bathroom? ______Yes _____ No

Development

Do you have any concerns about your child’s development? _____ Yes _____No

_____Hearing _____Vision_____Language_____Gross Motor_____Social_____Other

______

Has your child been evaluated for any of these developmental concerns? ______Yes _____No

Does your child currently have an Individualized Education Plan (IEP) or an Individual Family Service Plan (IFSP) ______Yes ______No *If yes, can you provide a copy to the center to assist with these needs.*

What is your child’s primary spoken language? ______

Are there other languages being used with your child? ______

Social and Emotional development

Has your child been in childcare before? _____Yes_____No

Is your child comfortable in group situations? _____ Yes_____No

What is your child’s regular routine when at home?______

______

What kinds of activities does your child enjoy? ______

Are there activities your child avoids? ______

Does your child have any siblings? ______

Does your family have any pets? ______If so, what kind? ______

What soothes your child? ______

What frightens your child? ______

Does your child have any favorite songs or games that comfort him/her? ______

What are your expectations or hopes for your child at our child care center? ______

______

What are your expectations for this center and the staff? ______

______

Person completing form: ______Mom_____Dad_____Other

Office use only

Form reviewed by ______(owner/director)

Initials ______

Date ______

Additional notes ______

______

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