BOTTINEAU CHILDREN'S ACADEMY ENROLLMENT PACKET

Please fill out these forms completely. If a question does not apply to your child, write N/A (not applicable). Enrollment fees and payment options will be discussed during the enrollment process.

Children’s Records must be maintained for at least five (5) years after a child has left the program to comply with the law.

Photo of child and physical description (optional).

Sex

General Information

Child's Date of Birth *

Allergies/Special Diets *

Name of Parent(s)/Guardian(s) *

Home address *

*if different than address above

Telephone Number *

*if different than number above

Parent(s)/guardian(s) business address/location during child care:

Name of Parent/Guardian *

Location of Parent/Guardian *

Other Parent/Guardian Information

Emergency Contact/Authorized pick-up person

In the event of an emergency when I may not be reached, the Educator may contact the following individuals (in the order given) whom I authorize to take my child from the child care premises

Emergency Contact's name *

Emergency Contact's Address *

Emergency Contact's Telephone *

Other Emergency Contact

AUTHORIZED PICK- UP

I additionally authorize the following individual to take my child from the child care premises. (Please let me know at the beginning of the day when your child will be picked up by one of the authorized individuals.)

Pick Up's Telephone *

Pick Up's Cellphone *

Other People Authorized for Pick-Up

Copies of any custody agreements, court orders, restraining orders (if applicable)

Notes for Custody Agreement

Anticipated Days/Time of Attendance

Monday: Arrival & Departure Time *

Tuesday: Arrival & Departure Time *

Wednesday: Arrival & Departure Time *

Thursday: Arrival & Departure Time *

Friday: Arrival & Departure Time *

Name of School Child Attends: *

Written Acknowledgement of Receipt of Parent Handbook

I acknowledge that I have received a copy of the parent handbook. *

Clear

Child's Physician or Health Care Professional

Health Provider's Name *

Health Provider's Telephone *

Health Provider's Address *

Information on allergies, special diets, chronic health conditions, special limitations, concerns including medications child is taking at home/school and possible side effects: *

Medical Insurance Information (optional)

Copy of Insurance Card

Parent/Guardian initials

Clear

Developmental History And Background Information

Regulations for licensed child care programs require this information to be on file to address the needs of children while in care.

Date of Birth of Child *

*Note: Please provide information for Infants and Toddlers (marked) as appropriate to the age of your child.

Developmental History

Please provide the age your child began doing the items listed below.

Does your child pull up? *

Yes

Does your child crawl? *

Yes

Does your child walk with support? *

Yes

Any speech difficulties? *

Special words to describe needs *

Language spoken at home *

Any history of colic? *

Yes

Does your child use pacifier or suck thumb? *

Yes

When do they use pacifier or suck thumb? *

Does your child have a fussy time? *

Yes

When does your child get fussy? *

How do you handle their fussy time? *

Any known complications at birth? *

Serious illnesses and/or hospitalizations? *

Special physical conditions, disabilities? *

Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions? *

Regular medications? *

Special characteristics or difficulties *

If infant is on a special formula, describe its preparation in detail *

Is your child fed held in lap? *

Yes

Is your child fed in a high chair? *

Yes

Does your child eat with Spoon? *

Yes

Does your child eat with Fork *

Yes

Does your child eat with Hands? *

Yes

Are disposable or cloth diapers used? *

Yes

Is there a frequent occurrence of diaper rash? *

Yes

What products do you for your child? *

If you selected other, please list it here

Are your child's bowel movements regular or irregular? *

Regular

Irregular

How many bowel movements per day does you child do? *

Is there problems with diarrhea? *

Yes

Is there problems with constipation? *

Yes

Have you attempted toilet training with your child? *

Yes

Please describe any particular procedure to be used for your child at the program *

What toilet product do you use at home? *

Potty chair

Special child seat

Regular seat

How does your child indicate bathroom needs with you? (include special words) *

Is your child ever reluctant or unwilling to use the bathroom? *

Does the child have accidents? *

What does you child use for sleep? *

Crib

Bed

Does your child become tired or nap during the day before their bed time (include when and how long)? *

Please Note: The American Academy of Pediatrics has determined that placing a baby on his/her back to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden and unexplained death of a baby under one year of age. If your child does not usually sleep on his/her back, please contact your physician immediately to discuss the best sleeping position for your baby. Please also take the time to discuss your child’s sleeping position with your educator. Your educator will place your infant on his/her back unless there is a written physician’s order that specifies otherwise.

When does your child get up in the morning? *

When does your child go to bed for the night? *

Describe any special characteristics, comforts, or needs (stuffed animal, story, mood on walking etc) *

Social Relationships

How would you describe you child's personality and behaviors? *

Below, please describe your child's...

Previous experience with other children/child care? *

Reaction to strangers *

Able to play alone *

Favorite toys and activities *

Fears (the dark, animals, etc.): *

How do you comfort your child *

What is the method of behavior management/discipline at home? *

What would you like your child to gain from this child care experience? *

Please describe your child’s schedule on a typical day. *

*For Infants, please include awakening, eating, time out of crib/bed, napping, toilet habits, fussy time, night bedtime, etc.

Is there anything else we should know about your child?

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