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clep 04:30 PM 09-25-2012
I do have one. I will copy and paste it here. I go through it verbally with the parents during the meet and greet to determine if I will accept their child. Our meet and greets are about 1.5 hours. It didn't paste very well, but here it is none the less.

Child Admission Record

Date of Enrollment:
Childís Name:
General Information:
Date of Birth:
Home Address:
Phone Number:
Father/Guardian Information:
Father or Guardian Name:
Fatherís Contact Phone Numbers: _________________________________________________
Address (if different from child):
Employer Name:
Employer Address:
Employer Phone Number:
E-mail Address:
Mother/Guardian Information:
Mother or Guardian Name:
Motherís Contact Phone Numbers:
Address (if different from child):
Employer Name:
Employer Address:
Employer Phone Number:
E-mail Address:
Emergency/Medical Information:
If neither parent nor guardian can be reached in case of an emergency call:
Childís Doctor (name, address, phone):
Childís Dentist (name, address, phone):
Childís Hospital of Choice:

Health #:
What illnesses has your child had in the past month?
What treatment was given?
When was the last prescription medicine given to this child?
Has your child had any illness in the past 24 hours?
If so, describe illness and treatment:
Allergies: __________________________________________________________________
Family/Home Information:
Other children in family (list relation):
Other adults in family (list relation):
Childís Normal Schedule:
Breakfast for the child usually consist of
Time the child usually eats breakfast
Time the child usually takes AM nap is
Time the child usually wakes up from AM nap is
Time the child usually eats lunch is
Time the child usually takes PM nap is
Time the child usually wakes up from PM nap is
Information About Child:
Please give information concerning your child, which will be helpful to the childcare provider.
Play Habits:
Eating Behavior:
Sleeping Pattern:
Likes and Dislikes:_______________________________________________________ Other:
The childís temperament is usually
Does the child have a comfort item for resting? Yes No If yes what is it?
Your routine for putting the child to sleep is

He/She likes to sleep on their Stomach, Back or Side
Is your child toilet trained?
If not, are they trying to use the toilet?
Do they require diaper some of the time, all of the time or not at all?
What words does he/she use for the bathroom?
Does your child have any special needs or behaviors I need to be aware of?

Previous Care:
Has your child been in care before? Yes No
How did your child respond to previous care? ____________________________________________________________________________________________________________________________________________________
How long was your child in previous care? __________________________________________
Can I contact the previous caregiver? Yes No
If no, why not? _____________________________________________________________
If yes: Providerís Name: ___________________________________
Providerís Number: __________________________________

Child Care Information:
Do you have a back-up provider? Yes No
If yes: Name, address, and phone number:
Are there any holidays you DO NOT want to participate in?
Are there any foods you DO NOT want your child to eat?
Any other information about your family or child that you wish us to know: __________________________________________________________________________


Permission for Activities:
I/We hereby give _____________ permission to take my/our child, , off the premises and on excursions that will take place during regular childcare hours. I understand that I will be notified of any such trips beforehand, that trips will be supervised and that all precautions will be made for the safety and well being of all the children. I/We also understand that _____________ will not be liable for any accident or injury.
Consent is for normal activities unless indicated below, the following activities may occur during the course of the day at ____________ Day Home.

Please initial those activities your child does not have permission to participate in:
Ride in provider's car (trips to the park, going to the store. Children will be in proper car seats during trips.)
Go for walks
Ride a bike
Play in water or sprinkler
Go to a park
Ride in wagon/stroller
Go on field trips
Visit neighbors
Are there any other activities in which your child should not participate?

Photo Permission:
I/We give permission for _______________ to use our childís photograph to send to parents and use for crafts. Your childís picture will not be given to anyone other than you. Parents will have pictures of all day home children as there are many group shots.

Child Release Information:
No child may be released from the providerís home to any person other than his/her parents or other person currently designated in writing by such parent to receive the child. Those people authorized to pick-up the child (including parents) need to present photo identification each day until easily recognized by the provider.

The following persons have my permission to pick up my child from the providerís home:

Name Phone
Relationship to child

Name Phone
Relationship to child

Name Phone
Relationship to child

I/We certify that all of the information given on this form is correct and accurate to our best knowledge. I/We promise that I/we will notify the provider, if any or all of the information changes.

Motherís Signature Date

Fatherís Signature Date

Providerís Signature Date