Parent Enrollment Form – FunTime Learning Center Inc.

Enrollment Form

Date :

Name:

Child’s Age:

Child’s Birthday:

Nickname :

Address:

Contact Information:

Mom's name :

Home Phone

Work Phone

Cell Phone

Dad’s name :

Home Phone

Work Phone

Cell Phone

Emergency Contact Person

Contact’s phone

Emergency Contact Person

Contact’s phone

Do you have a backup care provider?

Service Information:

Beginning date needing care

Monday Tuesday Wednesday Thursday Friday

Times you plan to drop your child off :

Times you plan to pick up your child :

CHILD'S HEALTH RECORD: (A copy of your child's immunizations and current physical will be needed)

General state of health:

Doctor’s name

Doctor’s phone number

Dentists’ name

Dentist's phone number

Are your child's immunizations up to date? (Please attach a copy of immunizations. This should include the signature of nurse or doctor who administered medications.)

Does your child have any known allergies?

Are you concerned that your child may be prone to any type of allergies? Describe:

Does your child have any medical conditions which I should be made aware of?

Has your child had the following common childhood illnesses? Does your child have any problems with any of these?

Constipation Convulsions Diarrhea Fainting Spells Frequent Colds Frequent Ear Infections Frequent Sore Throats Lice Ringworm Skin Rash Soiling Stomach Upsets Urinary Problem Worms

Has your child had any of these diseases?

Asthma Bronchitis Chicken Pox Diabetes Heart Disease Hepatitis Impetigo Measles Mumps German Measles Polio Scarlet Fever Tuberculosis Whooping Cough

Does your child have any speech, hearing or visual problems?

Would there be any restrictions to play or activities?

About Your Child:

Has your child ever been in child care before?

What type (center, family daycare, grandma etc.)

Was it a positive experience?

Why are you looking for child care?

How does your child feel about daycare and being left by his/her mommy/daddy?

Are there any recent traumatic situations the child has been exposed to such as a death in the family, divorce, new sibling etc.?

What is your normal method of discipline?

What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc.

Are there any food restrictions?

What is your child's favorite food?

What food does your child dislike?

Can your child be relied upon to indicate bathroom wishes?

What words does your child use for: Bowel movements urination

What time does your child awaken?

What time does your child go to sleep at night?

Do they sleep through the night?

Does your child sleep in a bed or crib, other?

Are there any siblings? Please name them and specify ages and gender.

Name:

Age:

Gender:

Has your child had experience playing with other children?

What language(s) are spoken at home?

Does your child have any security objects such as a blanket, soother, bottle, toy etc. ?

What are your child's favorite activities, toys, books, or games?

Are there any other comments or information you would like to let me know about?

Any specific concerns?