Little Embers Day School, Inc.
4050 Mercy Court
Murfreesboro, TN 37128
615-895-4741
615-895-4948
All information is required and must be completed by the parent(s) or legal custodian(s). If unknown, use N/A or none until it can be added later and initialed.
Child’s Information:
Child’s Birth Date: ______Date of Admission: ______
Full Name of Child:______What does the child like to be called: ______
Parent’s Information:
Mother’s Name______
Address:______
Phone: Home______Work ______Cell ______
Where employed: ______
Father’s Name ______
Address:______
Phone: Home ______Work ______Cell ______
Where employed:______
Custodial Parent (if divorced) ______(Copy of custody order provided?) Yes/No
Personal authorized to pick up and transport the child other than the parent or custodian: (Give full name and phone number of the person to whom the child may be released. They must be listed below to insure the child’s safety. A phone call is not acceptable permission of the parent(s) or custodian(s).
______
______
______
Emergency Information:
Name of person(s) and the phone numbers, other than the child care staff, authorized to act for the parent in an emergency.
______
______
______
______
Name of Physician: ______Office phone:______
Medical Association and address:______
Special written doctor’s instructions for care or medical treatment given ______
______
To whom any medical training/instructions/permission given:______
Any food/environmental/drug allergies: ______
Other children and members of the family:
Birthdate School/Work
______
______
______
______
Eating Habits:
What time does the child eat breakfast: ______Lunch ______Supper ______
Between meal snacks?______Does he/she feed him/her self?______
What is the child’s attitude toward eating?______
Does the child refuse to eat:______How is this handled and by whom? __
______
The child’s favorite foods: ______
(If your child is an infant, use a separate sheet for information about the formula, bottle schedule, etc. The parent must work closely with the child care facility while introducing new baby foods and table foods to the child.)
Developmental Health History:
What health problems has your child had in the past? ______
______
What health problems does your child have now? ______
______
Other than listed above:
Does your child have any allergies? If so, what and when? ______
______
How severe? ______
Does your child take any medication regularly? If so, what and when. ______
Has your child ever been hospitalized? If so, when and why? ______
Does your child have any recurring chronic illness or health problems such as:
___ Asthma ___ Cerebral Palsy ___ Developmental Delay ___ Seizure Disorder
___ Diabetes ___ Frequent Earaches ___ Hemophilia __Other ______
If medically diagnosed, what is the name of the doctor who diagnosed the illness or health problem: ______
Do you have any other concerns about your child’s health? ______
Developmental (compared with children your child’s age)
Does your child have any problems with walking, running or moving? Please explain: ______
______
Does your child have any problems seeing? Please explain: ______
______
Does your child have any problems hearing? Please explain: ______
Does your child have any problems using his/her hands (such as with puzzles, small building pieces)? Please explain. ______
Daily Living
What is your child’s typical eating pattern? ______
Is your child on any special diet? Please describe: ______
Write N/A (non-applicable) If you child is too young for the following questions to apply.
How well does your child use table utensils (cup, spoon, fork)? ______
How well does your child indicate bathroom needs? ______
Words for urination? ______
Words for bowel movement? ______
Special words for body parts? ______
What are your child’s regular bladder and bowel patterns? Do you want us to follow a particular plan for toileting? ______
For toddlers, please describe use of diapers or toileting equipment (such as potty, toilet seat adapter). ______
What is your child’s regular sleeping patterns? Awakes at ______
Naps at ______Goes to bed at ______
What help does your child need to get dressed? ______
______
Social Relationships/Play
What ages are your child’s most frequent playmates? ______
Is your child friendly? ______Aggressive? ______Shy? ______
Withdrawn? ______
Does your child play well alone? ______
What is your child’s favorite toy? ______
Is your child frightened by: ____ animals ___ rough children ___ loud noises
___ the dark ___ storms _____ anything else?
Who does most of the disciplining? ______
What is the best way to discipline your child, EXCLUDING physical punishment? ___
With which adults does your child have frequent contact? ______
Does your child use a special comforting item (such as a blanket, stuffed animal, doll)? ______
Is there any other information that you wish to share that would assist in meeting your child’s needs? ______
Note: The content of this health history has been taken from “Healthy Young Children: A Manual for Programs,” a publication of the National Association for the Education of Young Children, and used by permission. NAEYC, 1506 16th Street, N.W., Washington DC 20036-1426 Telephone numbers (202)232-8777 (800)424-2460 fax (202)324-1846
- I have received a summary of the licensing requirements.
- I do hereby authorize the child care facility’s staff to obtain emergency medical care for my child: (In some cases, such as military dependants, a limited power of attorney may be required by the child care facility).
- I visited the child care facility prior to enrolling my child.
- I have receive a copy of the child care facility’s parent policy statement or handbook, payment contract and signed their copy, verifying by receipt by understanding and agreement of their content.
- I understand any changes in the above information must be entered immediately and initialed.
- If you have any questions, concerns or complaints call Child Care Resource & Referral at 1-800-462-8261.
- I have been given a copy of the holiday schedule for the upcoming year.
- My child’s tuition fee per week is $______. I understand the fee is due every Monday by 6:00 p.m.
The above information is true and accurate to the best of my knowledge.
______
Signature of parent(s) or custodian(s) Date
Date child is enrolled: ______Date child is withdrawn: ______
Reason for withdrawal: ______
Special notes for child care facility or parent/custodian:
______