Application Form

Mom’s name________________________________________________
Dad’s name________________________________________________
Child’s name_______________________________________________
Child’s age_______________________________
Child’s Birthday________________________ Nickname____________________
Date______________________
Address_______________________________________________________________________________
_______________________________________________________________
(Mother)Home Phone_____________________________________
(Mother)Work Phone_____________________________________
(Mother’s) Cell Phone_____________________________________
(Father)Home Phone_____________________________________
(Father)Work Phone_____________________________________
(Father’s) Cell Phone_____________________________________
Fax Number___________________________________________
(Mother’s)
Email address:__________________________________________________________
(Father’s)
Email adreess___________________________________________________________
Mother’s Social Security #: __________________
Father’s Social Security #: __________________
Mother’s Driver’s License #: _________________
Father’s Driver’s License #: __________________
Parents are:
Married _____
Divorced _____
Separated _____
Widowed _____
Single _____
Mother's Employer (include name and address, telephone number and extension):
_______________________________________________________________________
_____________________________________________________________________________________
________________________
Telephone: ____________________
Hours of employment are from _________ a.m. To ____________p.m.
Father's Employer: (include name and address, telephone number and extension):
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________
Telephone: ____________________
Hours of employment are from ___________ a.m. To _____________p.m.
Beginning date needing care________________________________________________

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Hours: Monday___________________ Tuesday____________________
Wednesday______________________
Thursday________________________ Friday______________________
Times you plan to drop your child off________
Times you plan to pick up your child_________
Is there anyone besides you or your husband that
will be picking up your child. Yes or No
If yes Names____________________________________________________________
______________________________________________________________________
______________________________________________________________________
I will need a call the day of to let me know. This is for your child’s protection.
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?____________________________________________________________________
Will you be giving a two week notice to your current
provider?________________________________________________
Are there any areas you would like to see your child working
on?______________________________________________
What is your normal method of
discipline?_______________________________________________________________
What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc.
________________________________________________________________________
________________________________________________________________________
What are some of your child's favorite
activities?__________________________________________________________
Are there any food
restrictions?________________________________________________________________
Does your child have any special needs or
concerns?__________________________________________________________________
What are your child's napping
habits?__________________________________________________________________
What are your hopes/expectations for your child
here?______________________________________________________________________
_____________________________________________________________________________________
___________
Is someone available to pick up your child by closing
time?______________________________________________________________________
Do you have a backup care
provider?___________________________________________________________________
CHILD'S HEALTH RECORD: (A copy of your child's immunizations will be needed)
General state of health:
________________________________________________________________________

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________________________________________________________________________
Doctor’s name_____________________________________________________
Doctor’s phone number_______________________________________________
Dentists’ name_____________________________________________________
Dentists’ name _____________________________________________________
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?
. (please circle)
Does your child have any problems with any of
Has your child had any of these diseases?
these?
Constipation Asthma
Convulsions Bronchitis
Diarrhea Chicken Pox
Fainting Spells Diabetes
Frequent Colds Heart Disease
Frequent Ear Infections Hepatitis
Frequent Sore Throats Impetigo
Lice Measles
Ringworm Mumps
Skin Rash German Measles
Soiling Polio
Stomach Upsets Scarlet Fever
Urinary Problem Tuberculosis
Worms Whooping Cough

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

__________________________________________________________________________
Has your child ever been tested for the above?
__________________________________________________________________________
__________________________________________________________________________
Has your child ever had any surgeries or do they have any prosthetic limbs etc.?
__________________________________________________________________________
If yes, please describe:
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__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Would there be any restrictions to play or activities? I.e. Is your child handicapped, allergic to grass, etc.
________________________________________________________________________
________________________________________________________________________
Age your child began to: Sit __________, Crawl ___________, Walking _______________
Age your child began to: Talk _____________ Any difficulties with speech? Yes or No.
If yes to above question, please specify: ________________________________________
______________________________________________________________________
Have you made any special arrangement for child's care during illness? Yes or No.
Please specify: ___________________________________________________________
What is your child's favorite food? ____________________________________________
______________________________________________________________________
What food does your child dislike? ____________________________________________
______________________________________________________________________
Child’s favorite color______________________
Child’s favorite song______________________
Does your child know the basic shapes _________
ABC’s_______ colors________ numbers ___?
Does your child eat with a spoon _____ fork_____ hands______ ? (check all that apply)
Can your child be relied upon to indicate bathroom wishes? _________________________
Does your child have any fears related with toileting? ______________________________
Does your child have any "accidents"? _________________________________________
What words does your child use for: Bowel movements __________ urination___________
What words does your child use for describing his private parts? ______________________
______________________________________________________________________
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? ____________________________________
Does your sleep alone or with someone else? ____________________________________
______________________________________________________________________
Are there any siblings? Please name them and specify ages and gender.
Name _____________________ age __________________ gender _______________
Name ______________________ age __________________ gender _______________
Name ______________________ age __________________ gender _______________
Has your child had experience playing with other children? __________________________
______________________________________________________________________
Please give a brief description of your child's disposition. Is he friendly by nature, aggressive, shy,
withdrawn, imaginative, demanding? Etc.
_______________________________________________________________________
How does your child show his/her feelings?
When afraid: ____________________________________________________________
When happy: ____________________________________________________________
When angry: ____________________________________________________________
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When intolerant: __________________________________________________________
What forms of discipline are most often used in child's home?
________________________________________________________________________
________________________________________________________________________

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 language(s) are spoken at home?
________________________________________________________________________
Does your child have any security objects such as a blanket, soother, bottle, toy etc. ?
________________________________________________________________________
How does your child behave when he is sick?
_________________________________________________________________________
How is your child most easily settled when upset or afraid?
_________________________________________________________________________
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?
_________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
___________________________
Have you read my policies and
handbook?_______________________________________________________________
Are you in agreement with my payment policies and
procedures?_________________________________________________________________
_____________________________________________________________________________________
___________

Any specific
concerns?_____________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________________

Parent Signature: ___________________ Parent Signature: ________________________

Referral Sources
(Please circle all that applies)
ADVERTISEMENT REFERRAL
Drive-by Sign Parental Referral
5
Local Bulletin Center Referral
Flyer FIP Referral
Newspaper Subsidy Program Referral
Website Dept. Hum. Res