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Record & Registration
Children's Record & Registration Form
Child's Name
*
First
Middle
Last
Child's Birth Date
*
MM slash DD slash YYYY
Child's Nickname
Nickname
Gender
*
Female
Male
Non-binary
Child Lives With:
*
Both Parents
Mother
Father
if "other", please describe
Child's Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Primary Email Address
*
Secondary Email Address (optional)
Parent Marital Status
*
Single
Married
Partnered
Separated
Divorced
Widowed
Parent/Guardian Information
Parent/Guardian Name
*
First
Last
Parent/Guardian Cell Phone
*
Employer Name
Business Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Business Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Occupation
Work Phone
*
Best way to reach Parent/Guardian while child is at the Center:
*
Cell Phone
Work Phone
Parent/Guardian 2 Name
First
Last
Parent/Guardian 2 Cell Phone
Employer Name
Business Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Occupation
Work Phone
Best way to reach Parent/Guardian 2 while child is at the Center:
Cell Phone
Work Phone
Approved Pickup
Name(s) and telephone of other adults authorized to take child from the Center different from parents:
1.
2.
Emergency Contacts
Must be filled out completely and cannot include parents/guardians listed above
Emergency Contact 1 - Name
*
First
Last
Emergency Contact 1 - Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Emergency Contact 1 - Phone
*
Emergency Contact 1 - Relationship
*
What is this person's relationship to the child?
Emergency Contact 2 - Name
*
First
Last
Emergency Contact 2 - Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Emergency Contact 2 - Phone
*
Emergency Contact 2 - Relationship
*
What is this person's relationship to the child?
Child's Health Information
Has your child been seen by a medical specialist other than their regular MD?
*
Yes
No
Please Describe:
Is your child taking any medications now?
*
Yes
No
including laxatives, vitamins, etc.
Please Describe:
Do you have concerns about your child's hearing or vision?
*
Yes
No
Please Describe:
Please Describe:
Has your child had any serious accidents/poisonings/hospitalizations?
*
Yes
No
Please Describe:
Has your child had any of the following?
*
3+ ear infections in the last year
3+ colds with fever in the last year
Premature birth
Birth injury/defect
Trouble breathing at birth
Convulsions/seizures
Head injury
Allergies (Eczema, hives, drug/food intolerance, hay fever, wheezing, asthma, insect stings)
None of the above
Please Describe:
Please describe any other specific dietary, medical or other individual needs not previously mentioned.
Please describe previous enrollment your child has had in other care settings (centers/in-home/family, etc.)
Does your child experience any notable difficult behavioral issues or have you ever been referred to an alternate care setting for behavioral reasons?
*
Yes
No
Please Describe:
Have you made special arrangements for the care of your child should they become ill at the Center?
*
Yes
No
All Children - Personality & Additional Information
Please describe your child's personality:
*
What are your child's favorite activities?
*
Does your child enjoy playing with others?
*
Yes
No
What are the primary and secondary languages spoken at home?
*
Please describe your child's communication behavior:
*
Please describe how your child responds to interaction with adults and other children and to being separated from parents:
*
How do you comfort your child?
*
(Does your child have a special blanket, stuffed animal, or toy they use for comfort?)
Please describe any other special needs, fears, or concerns you have about your child that you would like us to know about:
*
Is there any information you would like us to know related to your child's/family's race, religion, home language, culture, or family structure?
*
(enter none, if no additional information is necessary)
What goals do you have for your child?
*
(Social, Emotional, Physical)
Please list any other children in the household.
*
(Name, Age, Relationship, or enter "none" if not applicable)
Please list any other adults who are regularly in the household.
*
(Name, Age, Relationship, or enter "none" if not applicable)
Please list any other important people in your child's life.
*
(Name, Age - if applicable, Relationship)
For Children 33 Months to 5 Years
Please complete the following section for children in this age group - if your child is younger, skip down to the section for infants and toddlers.
Please describe your child's sleeping habits:
(naps - frequency and length)
Please describe your child's toileting habits:
(fully toilet trained, needs help, other?)
Please describe your child's dressing habits:
Are there any behavior guidance techniques you use with your child that work well?
Infants & Toddlers 2 to 32 Months
Please complete this section if your child is between the ages of 2 months to 32 Months
Do you have any special way of helping your child go to sleep?
Does your child cry when they go to sleep?
What is your child's current sleeping schedule?
Does your infant (2-15 months) prefer to sleep on their stomach, side, or back?
(skip if not applicable)
Does your child use a pacifier
Yes
No
Sometimes
Does your child need a blanket or toy to sleep?
Yes
No
Sometimes
Will your baby drink breast milk or formula at the Center?
Breast Milk
Formula
What type of formula do you use?
What type of bottle do you use?
Has your child had any feeding problems?
(please enter "none" if not applicable)
Do you use cloth or disposable diapers?
Does your child experience diaper rash and how do you treat it?
Special Note
You've indicated your child will be drinking breast milk or formula. Please fill out a feeding schedule provided by the Center prior to bringing your child for their first day.
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