Registration Form

Little Miracles Christian Child Care Centre

Registration Form

Name of Child:_____________________________Child responds to:__________________

Address:________________________________________

Phone:_________________________________ 

Sex: M_____F_____ Date of Birth:__________________

Enrollment Date:___________________

PARENTS/GUARDIANS:

Name:______________________________ Home:_________________

Work:__________________   Cell:____________________

Name:______________________________Home:_________________

Work:__________________  Cell: ____________________

Parent’s are (please circle): Married / Divorced / Separated / Widowed / Single

Parent/Guardian with Legal Custody_______________________________.

Parent/Guardian shares joint custody: Yes _____ No _____ (if yes, a copy of the order may be needed).

ALTERNATE PERSON(S) to call in an emergency or authorized to pick child up: (min. of 2 and all must be within a 20 mile radius)

#1) Name:__________________________ Relationship:________________

Home:_______________  Cell:_______________ Work: _______________

#2) Name:__________________________Relationship:_________________

Home: _______________  Cell: ______________  Work: _______________

#3) Name:__________________________Relationship:_________________

Home:_______________  Cell: _______________  Work: _______________

MEDICAL & HEALTH INFORMATION :

Family Dr:________________________________ Phone:___________________

Med #:__________________

* Known health problems/special comments: _____________________________________

___________________________________________________________________________

* Special Medications child must receive, (please supply a Dr.’s note stating instructions):

________________________________________________________________________

________________________________________________________________________

* Vision, Hearing or Speech Challenges: _________________________________________

_________________________________________________________________________________

* Allergies: Yes ______ No ______ (If YES please describe): ________________________

________________________________________________________________________

* Special Diet (for reasons of Health, Religion, Ethnicity):____________________________

__________________________________________________________________________________

Please circle all communicable diseases your child has or has had:

Chicken Pox

Shingles

German Measles

Measles

Mumps

Other: ___________________________________________________________________

Is your child prone to (please circle all that apply):

Stomach upsets

Colds

Headaches

Sore throats

Ear aches/infections

Reflux

Spitting Up

Drooling

Has he/she had any recent serious illness? Yes ( ) No ( )

If YES please explain: ______________________________________________________

_______________________________________________________________________

Is child toilet trained: Yes ( ) No ( ) Words used by child for toileting:_________________

Does your child have any mental or physical disabilities? Yes ( ) No ( ) If YES please

explain: _____________________________________________________________________

If your child is drinking formula do they prefer it cold_____ or warm______?

How would you describe your child’s personality (please circle all that apply):

Affectionate

Active

Easy Going

Clingy

Cuddly

Curious

Demanding

Grumpy

Happy

Out Going

Sensitive

Spirited

Shy

Temperamental

Touchy

Vocal

Has your child had any previous experience away from home or you? (Day Care, Play Groups, etc.):

Yes ____ No _____ If Yes Please List:__________________________________________

__________________________________________________________________________________

If child was previously enrolled in Daycare why was care terminated:  ____________________

__________________________________________________________________________________

Previous Child Care Providers Name & Number:__________________________________

May I contact them for a reference? Yes_____ No _____ (If yes please contact them to let them know that I may be calling.)

Does your child have a regular nap schedule?   Yes _____ No _____

If Yes when and how long:____________________________________________________

Does your child have sleep apnea? Yes _____ No _____    Night Terrors? Yes _____ No _____

Walk in their sleep? Yes _____ No _____

What time does your child usually wake in the morning? ______________________________

What is your childs disposition when waking (please circle):

Happy

Grumpy

Clingy

Please list your child’s favorite activities:_________________________________________

___________________________________________________________________________________

* What are your wishes for your child while they are enrolled here or comments:

_______________________________________________________________________

_______________________________________________________________________