Online Enrollment

You can now use our online form to enroll your child. Follow the instructions listed and make sure to fill in all relevant fields.

Child's Information Child's Birth Date:* Child's First Name:* Child's Middle Name: Child's Last Name:* What does the child like to be called:*

Parent's Information

Mother

First Name:* Last Name:* Address:* Phone (Home):* Phone (work):* Where Employed:* Hours:*

Father

First Name:* Last Name:* Address:* Phone (Home): Phone (Work):* Where Employed:* Hours:* Misc. Information:

Custodial Parent if divorced:

First Name Last Name

Family Information

Other children and members of family:

Family Member 1

First Name Last Name Birth Date: School/Work:

Family Member 2

First Name Last Name Birth Date: School/Work:

Family Member 3

First Name Last Name Birth Date: School/Work:

Family Member 4

First Name Last Name Birth Date: School/Work:

Family Member 5

First Name Last Name Birth Date: School/Work:

Family Member 6

First Name Last Name Birth Date: School/Work:

Authorized Persons

Persons authorized to pick up and transport the child other than 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 ensure the child's safety. A phone call is NOT acceptable permission of the parent(s) or custodian(s).

Person 1

First Name: Last Name: Phone (home): Phone (work):

Person 2

First Name: Last Name: Phone (home): Phone (work):

Person 3

First Name: Last Name: Phone (home): Phone (work):

Person 4

First Name: Last Name: Phone (home): Phone (work):

Emergency Information

Name of person(s) and the telephone number(s), other than the child care staff, allowed to act for the parent(s) in an emergency:

Emergency Contact 1

First Name:* Last Name:* Address:* Phone (home):* Phone (work):* Where Employed:* Hours:*

Emergency Contact 2

First Name:* Last Name:* Address:* Phone (home):* Phone (work):* Where Employed:* Hours:*

Physician Information:

First Name:* Last Name:* Phone (office):* Phone (home): Medical Association:* Association Address:* Chart Number: Special written doctor's instructions for care or medical treatment give the child care: To whom any medical training and/or instructions and permission given: Any food, environmental, and/or medical allergies (separated by commas):

Eating Habits What is your child's typical eating pattern?*

Is your child on any special diet?*

Yes No Please describe: When does the child eat breakfast?* Lunch?* Dinner?* Between meal snack?* What is the child's attitude toward eating?*

Does he/she feed him/herself?*

Yes No

Does the child ever refuse to eat?*

Yes No How is this handled and by whom? Child's favorite foods (separated by commas):*

Daily Living

Potty Training: Is your child Potty Trained?*

Yes No

Does your child need assistance using the bathroom?*

Yes No

Type in "N/A" if your child is too young for the following questions to apply:

How well does your child use table utensils (cups, forks, spoons, etc)?* How does your child indicate bathroom needs?* Words for urination (separate by commas):* Words for bowel movement (separate by commas):* 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 the use of diapers or toileting equipment (such as potty, toilet scat adapter, etc):*

What are your child's regular sleeping patterns?

Wakes at:* Naps at:* Goes to bed at:* What help does your child need to get dressed?*

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 (NAEYC), and used by permission.

NAEYC, 1509 16th Street, N.W., Washington, D.C. 20036-1426
Telephone: (202) 232-8777 (800) 424-2460
Fax: (202) 324-1846