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child_profile
Child Daycare Profile
Child Daycare Profile
Child Name
First
Last
Parent Name
First
Last
Phone Number
Email
Child Date of Birth
YYYY dash MM dash DD
Does your child speak English?
Yes
No
Does one parent speak English?
Yes
No
Please select how active your child is
0 - I am not sure if my child is active yet
1 - My child is not active
2 - My child is active
3 - My child is extremely active
Has your child attended daycare preschool/afterschool before?
Yes
No
If yes, for how long did your child attend preschool/afterschool?
less than 6 months
6 months
1 year
2 years or more
Does your child need help with the following? (check any that apply)
Dressing/Undressing
Eating
Toileting
Handwashing/Toothbrushing
Does your child require additional support (i.e. autism, ADHD, etc)?
Yes
No
If yes, check any that apply
Autism
ADHD
ADD
Other
Does your child have any allergies? (If yes, please describe)
Does your child take any medication? (If yes, please describe the medications)
Does your child currently have an Educational Assistant (EA) while attending school?
My child does not go to school yet
Yes
No
Tell us a few things about your child
What does your child like to do? (i.e. :look at books, listen to music, play with other children, play outdoors/indoors, toys, climb/run/jump, paint, computer, imaginative play/dress-up)
Is there anything else you would like to share with us about your child?
Phone
This field is for validation purposes and should be left unchanged.
Play, Have Fun, Enjoy Life!
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