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Enrollment Application
Child's Name
Mother's Name
Child's Birthday
Father's Name
Address
Email
Mother's Home Phone
Mother's Work Phone
Mother's Cell Phone
Emergency Contact Person #1
Emergency Contact Person #2
Father's Home Phone
Father's Work Phone
Father's Cell Phone
Emergency Contact #1's Phone
Emergency Contact #2's Phone
Do you have a backup care provider? If so, please provide name and contact info:
Beginning date needing care
Care options, please choose one:
Part-time Care (2 days/20 hours/week) Monday and Wednesday 7:30am-5:30pm
Part-time Care (2 days/20 hours/week) Tuesday and Thursday 7:30am-5:30pm
Time you plan to drop your child off
Time you plan to pick you child up
Child's general state of health
Doctor's Name
Dentist's Name
Doctor's Phone
Dentist's Phone
Are you child's immunizations up to date?
Yes
No
Does your child have any allergies? If so, please describe:
Does your child have any medical conditions which I should be made aware of?
Does your child have any speech, hearing, or visual problems?
Would there be any restrictions to play or activities?
Has your child ever been in child care before? If yes, please specify type (center, family, daycare, Grandma, etc.)
Was it a positive experience?
How does your child feel about starting preschool?
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 foods does your child dislike?
Can your child be relied upon to indicate bathroom wishes?
What words does your child use for bowel movements and urination?
What time does your child awaken?
12:00 AM
12:15 AM
12:30 AM
12:45 AM
01:00 AM
01:15 AM
01:30 AM
01:45 AM
02:00 AM
02:15 AM
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04:45 AM
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06:45 AM
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07:15 AM
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07:45 AM
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08:45 AM
09:00 AM
09:15 AM
09:30 AM
09:45 AM
10:00 AM
10:15 AM
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10:45 AM
11:00 AM
11:15 AM
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11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
01:00 PM
01:15 PM
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01:45 PM
02:00 PM
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07:00 PM
07:15 PM
07:30 PM
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08:00 PM
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08:45 PM
09:00 PM
09:15 PM
09:30 PM
09:45 PM
10:00 PM
10:15 PM
10:30 PM
10:45 PM
11:00 PM
11:15 PM
11:30 PM
11:45 PM
06:30 AM
What time does your child go to sleep at night?
12:00 AM
12:15 AM
12:30 AM
12:45 AM
01:00 AM
01:15 AM
01:30 AM
01:45 AM
02:00 AM
02:15 AM
02:30 AM
02:45 AM
03:00 AM
03:15 AM
03:30 AM
03:45 AM
04:00 AM
04:15 AM
04:30 AM
04:45 AM
05:00 AM
05:15 AM
05:30 AM
05:45 AM
06:00 AM
06:15 AM
06:30 AM
06:45 AM
07:00 AM
07:15 AM
07:30 AM
07:45 AM
08:00 AM
08:15 AM
08:30 AM
08:45 AM
09:00 AM
09:15 AM
09:30 AM
09:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
01:00 PM
01:15 PM
01:30 PM
01:45 PM
02:00 PM
02:15 PM
02:30 PM
02:45 PM
03:00 PM
03:15 PM
03:30 PM
03:45 PM
04:00 PM
04:15 PM
04:30 PM
04:45 PM
05:00 PM
05:15 PM
05:30 PM
05:45 PM
06:00 PM
06:15 PM
06:30 PM
06:45 PM
07:00 PM
07:15 PM
07:30 PM
07:45 PM
08:00 PM
08:15 PM
08:30 PM
08:45 PM
09:00 PM
09:15 PM
09:30 PM
09:45 PM
10:00 PM
10:15 PM
10:30 PM
10:45 PM
11:00 PM
11:15 PM
11:30 PM
11:45 PM
07:30 PM
Do they sleep through the night?
Are there any siblings? Please name them and specify ages and 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?
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