Child's Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Parent/Guardian Completing This Form
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Preferred Method of Communication
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Provider/Center Name
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Has Your Child Attended Child Care in the Past?
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If yes, what type of setting was the child in (i.e. family child care, group care, etc.)
What did you like most about your child's previous child care setting?
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What did you like least about your child's previous child care setting?
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What is important to you about your child's care?
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Who is important to your child?
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Does your child prefer to play alone or with other children?
If yes, what is it?
Does your child have a favorite toy or comfort object?
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What is your child's current sleep schedule?
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Does your child fall asleep easily?
What is his/her mood upon waking?
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What does your child like?
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What does your child dislike?
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Special things you say or do to comfort your child are:
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How do you know when your child is each of the following emotions?
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Happy, sad, mad, tired, other.
How does your child react when something unexpected happens?
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How does your child react when something happens he/she doesn't like?
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How does your child react when he/she is scared?
Does your child have any health issues?
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If yes, please explain
Does your child have any other special needs?
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If yes, please explain
Has anything happened recently in your child’s life that might have an effect on him/her?
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Events at home often influence a child’s behavior, for example: changes in the family, such as a new
sibling, separation or divorce, or moving to a new home. Knowing about these transitional times will
allow us to provide special attention, understanding, and care that your child needs.
Is there anything else you would like to share about your child that you feel would help us create a positive environment and relationship with your child?
Parent/Guardian declined to complete
Parent/Guardian Name
*
When printing your name, you are acknowledging the printed name on this document will act as your
temporary authorization and we will require you to sign the documents in person
First Name
Last Name
Today's Date
MM
DD
YYYY
Parent/Guardian Signature
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First Name
Last Name
Today's Date
MM
DD
YYYY
