Regulations for licensed child care facilities require this
information to be on file to address
the needs of children while in care.
Child’s Name_____________________________________ Date of Birth____________________
Age began sitting__________ crawling__________ walking__________ talking________________
Any speech difficulties? ___________________________________________________________
Special words to describe needs_____________________________________________________
Any known complications at birth? ___________________________________________________
Serious illnesses and/or hospitalizations: _______________________________________________
Special physical conditions, disabilities: ________________________________________________
Allergies (e.g., asthma, hay fever, insect bites, medicine, food reactions):_______________________
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Regular medications: ______________________________________________________________
Special characteristics or difficulties: __________________________________________________
Favorite foods: __________________________________________________________________
Foods refused: __________________________________________________________________
How does child indicate bathroom needs (include special words): ____________________________
Is child ever reluctant to use the bathroom? _____________________________________________
Does child have accidents? _________________________________________________________
Does child become tired or nap during the day (include when and how long)? ___________________
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When does child go to bed at night?_____________ and get up in the morning? _________________
Describe any special characteristics or needs (stuffed animal, story, mood on waking, etc.):
______________________________________________________________________________
How would you describe your child:__________________________________________________
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Previous experience with other children/day care_________________________________________
Reaction to strangers:_____________________________ Able to play alone:__________________
Favorite toys and activities:_________________________________________________________
Fears (the dark, animals, etc.): ______________________________________________________
Optimum way to comfort child when sad, angry, etc.: _____________________________________
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What is the method of behavior management/discipline at home? _____________________________
______________________________________________________________________________
Describe your child’s schedule on a typical day: _________________________________________
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What would you like your child to gain from this experience? ________________________________
______________________________________________________________________________
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Is there anything else you would like us to know about your child? ____________________________
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Parent’s/Guardian’s Signature: ______________________________________________________
Date: _______________________________