Enrollment Packet
Enrollment Packet
Enrollment Packet
Date of Discharge
Allergies/Special Diets
Name of Parent(s)/Guardian(s)
Telephone Number:
Email Address: _
My child will arrive to the program by: My child will depart the program by:
Parent Drop-Off Parent Pick Up
Supervised Walk Supervised Walk
Unsupervised Walk Unsupervised Walk
Public/Private Van Public/Private Van
Bus Program Bus/Van
Private Transportation Provided by Parent Private Transportation Provided by Parent
In the space below, please note any important information regarding transportation of your child to and from the
program (i.e.--indicate who will be supervising children during transport or prior to their arrival at the program, who
supervises the walk from a bus stop, etc.)
I additionally authorize the following individual to take my child from the child care premises. (Please let me know
at the beginning of the day when your child will be picked up by one of the authorized individuals.)
Name Address
Name Address
Day Arrival Time Departure Time Day Arrival Time Departure Time
Monday Friday
Tuesday Saturday
Wednesday Sunday
Thursday
□ Copies of any custody agreements, court orders, restraining orders (if applicable) Notes:
Child’s Name
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Written Acknowledgement of Receipt of Parent Handbook
I acknowledge that I have received a copy of the provider’s parent handbook as well as information regarding
lead poisoning prevention (may be included in the parent handbook).
Parental Signatures
Parent/Guardian Date
I understand that I may visit this family child care home unannounced at any time during the hours that my child
is in care.
Parent/Guardian Date
Name: Telephone:
Address:
Information on allergies, special diets, chronic health conditions, special limitations, concerns including medications
child is taking at home/school and possible side effects:
Type of Insurance:
I certify that documentation of physical examination and immunizations in accordance with public school health requirements, and lead
Parent/Guardian initials:
Child’s Name
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DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION
Regulations for licensed child care programs require this information to be on file to address the needs of children while in
care.
*Note: Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child.
DEVELOPMENTAL HISTORY
HEALTH
Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions:
Regular medications:
EATING HABITS
Favorite foods:
Foods refused:
* Is your child fed held in lap? High chair?
* Does your child eat with Spoon? Fork? Hands?
TOILET HABITS
What is used at home? Potty chair? special child seat? regular seat?
How does your child indicate bathroom needs (include special words):
Is your child ever reluctant to use the bathroom?
Does the child have accidents?
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SLEEPING HABITS
Please Note: The American Academy of Pediatrics has determined that placing a baby on his/her back
to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden and
unexplained death of a baby under one year of age. If your child does not usually sleep on his/her
back, please contact your physician immediately to discuss the best sleeping position for your baby.
Please also take the time to discuss your child’s sleeping position with your educator. Your educator
will place your infant on his/her back unless there is a written physician’s order that specifies
otherwise.
When does your child go to bed at night? and get up in the morning?
Describe any special characteristics or needs (stuffed animal, story, mood on walking etc)
SOCIAL RELATIONSHIPS
What would you like your child to gain from this child care experience?
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Permissions (for each child enrolled)
General Permission-(Basic Transport) (Parents should not sign this permission unless
specific places where your child is allowed to go are listed by your educator.) By signing this form, I am allowing
my child to be taken off the child care premises.
off the premises of the family child care home for the following excursions: (specific places your child is allowed
to go):
treatment when I cannot be reached or when delay would be dangerous to my child's health.
Topical Medication/Ointments (Please list only those medications/ointments which you will allow the
educator(s) to administer to your child's skin): Ex: sunscreen, insect repellent (bug spray), diapering ointment.
Child’s Name
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Emergency Card Information
REMINDER : This emergency card information is for the educator’s first aid kit. The educator(s)
must take first aid materials when leaving the child care premises.
Phone:
2.
(Name, Address, Home and Cell Phone #)
2.
(Name, Address, Home and Cell Phone #)
Parent/Guardian Date
Subscriber's Name:
Type of Insurance:
Policy Number:
[ ] Copy of insurance card
Other pertinent medical information:
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Dear Physician:
(Child's Name)
is enrolled in a family child care home which is licensed by the Department of Early Education and Care. The
Department of Early Education and Care’s regulations require at the time of admission a written statement from a
physician as evidence of each child's annual physical examination, immunizations and lead screening in accordance
with Department of Public Health's recommended schedules. A prompt response is appreciated.
Evidence of a physical exam is valid for one (1) year from the date the child was examined and must be renewed
annually thereafter.
IDENTIFICATION
Address: Phone #
Name of Parents:
Address:
What is your opinion concerning the child's general health and appearance:
(*At least one (1) time between ages 9-12 months; Annually-Ages 2 & 3; at Age 4 if High Risk for Lead Poisoning)
Does this child have any disabilities or chronic medical problems (allergies, limited vision, etc.) which require special
consideration or care by the child care educator? If so, please detail below:
Comments:
Please return this form and the child’s immunization record to:
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