Child Intake Form

1. Child's General Information

Child's Full Name

Child Gender

Date of Birth

Start Date

Days and Hours of Attendance

Primary Language

2. Parent/Guardian & Payment Information (for Contract)

Parent/Guardian Name #1

Parent/Guardian Contact #1

Parent/Guardian Name #2 (Optional)

Parent/Guardian Contact #2 (Optional)

Full Address

Payment Term (e.g., Bi-weekly, Monthly)

Fees Due Date (e.g., 1st of month)

Late Payment After (e.g., 5th of month)

Late Fee Amount

3. Emergency Contact & Physician Information

Emergency Contact Information

Emergency Contact Name #1

Emergency Contact Number #1

Emergency Contact Name #2 (Optional)

Emergency Contact Number #2 (Optional)

Physician Information

Physician's Name

Physician's Contact Number

Clinic/Hospital Name

Email (Optional)

Health Insurance Provider

Health Insurance Policy Number

4. Dietary & Allergy Information

Dietary Preferences & Restrictions

Does the child have any specific dietary preferences or restrictions (e.g., vegetarian, halal)?

Yes No

Is the child a picky eater or have any particular food dislikes?

Yes No

Please provide details about any dietary preferences, restrictions, food dislikes, or cultural/religious considerations regarding meals and snacks:

Allergies & Reactions

Does the child have any known allergies (food, environmental, medication, etc.)?

Yes No

Are there any specific actions to take in case of an allergic reaction?

Yes No

Please list all known allergies (food, environmental, medication, etc.), provide details about the type of reaction, necessary precautions, and specific actions to take (e.g., EpiPen administration, specific rescue inhaler):

4. Health Conditions & Medications

General Health & Medical History

Please provide details about any chronic health conditions, significant medical conditions or diagnoses, past hospitalizations or surgeries, and any special needs staff should be aware of:

Immunizations: Please provide information regarding the child's up-to-date immunization status, including the date of the last immunizations received.

Medication Information

Is the child currently under any medication (prescription, over-the-counter, supplements)?

Yes No

Does medication need to be administered during daycare hours?

Yes No

If yes to any of the above, please list all current medications, dosage, time of administration, and reason for medication:

5. Child Development & History

Pregnancy and Birth History

Pregnancy Duration

Birth Weight (lbs)

Birth Weight (oz)

Any complications during pregnancy or birth:

Self-Feeding Habits

Is the child able to feed themselves independently?

Yes No

If the child requires assistance with utensils or feeding, please provide details:

Toilet Habits

Is the child currently in the process of toilet training?

Yes No

Please indicate whether the child wears diapers or is potty trained.

Diapers Potty Trained

Please provide details about toilet training instructions/techniques, or assistance needed with toileting (e.g., Needs reminder every 2 hours, uses a potty seat. If wears diapers, specify preferred brand/size):

Sleeping Habits

Specify the child's typical nap schedule, including the duration and frequency of naps.

Describe any specific naptime routines or comfort items that help the child sleep.

Developmental Milestones

Please indicate the approximate age at which your child started the following milestones:

Crawled, walked, etc. (Gross Motor Skills)

Grasping objects, using utensils, etc. (Fine Motor Skills)

Babbling, saying first words, forming sentences, etc. (Speech and Language Skills)

Smiling, showing emotions, engaging with others, etc. (Social and Emotional Skills)

Recognizing shapes, solving puzzles, etc. (Cognitive Skills)

Educational History

Current educational setting (e.g., daycare, preschool):

Any previous educational experiences:

Any concerns or challenges related to learning or behavior:

Family History

Names and ages of siblings:

Family dynamics or significant events that may impact the child's development:

Any family history of developmental delays, learning disabilities, or other relevant conditions:

6. Other Important Information

Transportation Authorization

Name of Authorized Person

Relationship

Contact Number

Specific Instructions for Transportation

Additional Information

Please share more details about your child's interests, preferences, or strengths to enhance our understanding of them.