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
Parent's Information

Mother

Father

Custodial Parent if divorced:

Family Information

Other children and members of family:

Family Member 1

Family Member 2

Family Member 3

Family Member 4

Family Member 5

Family Member 6

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

Person 2

Person 3

Person 4

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

Emergency Contact 2

Physician Information:

Physical Health History

Does your child have any allergies?*

Does your child take any medication regularly?*

Has your child ever been hospitalized?*

Does your child have any recurring chronic illness or health problems such as...

Developmental History

Does your child have any problems with talking or making sounds?*

Does your child have any problems with walking, running, or moving?*

Does your child have any problems seeing?*

Does your child have any problems hearing?*

Does your child have any problems using his/her hands (like puzzles, small parts)?*

Eating Habits

Is your child on any special diet?*

Does he/she feed him/herself?*

Does the child ever refuse to eat?*

Daily Living

Potty Training: Is your child Potty Trained?*

Does your child need assistance using the bathroom?*

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

What are your child's regular sleeping patterns?

Social Relationships/Play

Is your child friendly?*

Is your child ggressive?*

Is your child shy?*

Is your child withdrawn?*

Is your child frightened by...

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