First Steps Children S Center

First Steps Children's Center

Infants and Toddler Enrollment Form

For center use only:

Admission Date:______

Admission Age:______

Child's Name______Primary Language______

Date of Birth______Place of Birth______

Information on the Father: Information on the Mother:

Fathers Name______Mothers Name______

Address______Address______

______

Home Phone______Home Phone______

Cell Phone______Cell Phone______

Employer Name______Employer Name______

Employer Address______Employer Address______

______

Employer Phone______Employer Phone______

Working Hours______Working Hours______

If Parents Cannot be Contacted, Notify:If Parents Cannot be Contacted, Notify:

Contact Name______Contact Name______

Address______Address______

Telephone______Telephone______

Relationship______Relationship______

Others in Family Relationship______

Child's Physician / Clinic ______

Child's Identifying Information (required by the Office of Child Care Services)

Eye Color______Height______Sex______

Hair Color______Weight______Race______

Any Other Identifying Marks______

PARENT'S SIGNATURE: ______DATE______

First Steps Children’s Center

Developmental History and Background Information

Infant and Toddler

Regulations for licensed childcare facilities require this information to be on file to address the needs of children while in care. (Form GDC-13c)

Child’s Name: Date of Birth:

Personal History

Type of Birth: ______Any complications? ______

Health

Any known complications at birth: ______

Serious illnesses and/or hospitalization: ______

Special physical conditions, disabilities: ______

Allergies i.e. asthma, hay fever, insect bites, medicine, or food reactions: ______

Regular medications: ______

Eating Habits

Are there any special feeding problems (including special diets)? ______

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

Favorite foods: ______

Foods refused: ______

Does your child eat with: _____hands, _____spoon, _____fork, or _____all.

Is your child fed in a; _____lap, _____ high chair, _____ other.

Toilet/Diapering Habits

Is there frequent occurrence of diaper rash? ______

Do you use; _____oil, _____powder, _____lotion, _____other.

Are plastic pants used? ______

Are bowel movements regular? _____ How many per day? _____ Usual time? _____

Is there a problem with diarrhea? ______Constipation? ______

Has toilet training been attempted? ______

Please describe any particular procedure to be used for your child at the center: ______

What is used at home? _____ Potty chair, _____ special child seat, _____ regular seat

How does your child indicate his/her bathroom needs? ______

What words are used at home for urination ______bowel movement? ______

Is your child ever reluctant or frightened to use the bathroom? ______

Does your child ever have accidents? ______

Sleeping Habits

Does your child sleep in a crib? _____ or bed? _____

When does your child take his or her nap? (when and how long)? ______

When does your child go to sleep at night? _____ and get up in the morning? _____

Describe any special characteristics, needs, and mood. (Stuffed animal, blanket, story) ______

Social Relationships

Does your child have previous experience with other children? ______

By nature is your child: _____friendly, _____aggressive, _____shy, _____withdrawn?

Reaction to strangers: ______

Is your child able to play alone: ______

What are your child’s favorite toys or activities: ______

What does your child fear (dark, lightning, bugs.): ______

How do you comfort your child: ______

What type of behavior management is used at home: ______

Describe your child’s schedule on a typical day. (Approximate time, activities, awakening, eating, napping, diapering/toileting habits, fussy times bedtime, etc.) ______

______

Is there anything you would like us to know about your child?

______

Parent/Guardian Signature: ______Date: ______

First Steps Children’s Center

30 Giasson Street * Hudson, MA 01749 * (978) 562-6862

17 Oregon Road * Southborough, MA 01772 * (508) 481-1437

Emergency Care - Authorization and Consent Form

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child (name)______. However, if I cannot be reached, I hereby authorize First Steps Children's Center to transport my child to the (hospital name)______Hospital and to secure for my child the necessary treatment. I understand the teachers in the day care center are trained in the basics of first aid and I authorize them to give my child first aid when appropriate.

*Parent Signature: ______Date: ______

Child Release - Authorization and Consent Form

I hereby authorize First Steps Children's Center to release my child to the following persons (other than the parents):

Name: ______Relationship: ______

Address: ______Telephone #: ______

Name: ______Relationship: ______

Address: ______Telephone #: ______

Name: ______Relationship: ______

Address: ______Telephone #: ______

*Parent Signature: ______Date: ______

First Steps Children’s Center

Emergency Evacuation Information Sheet

Child’s Name: ______Date of Birth: ______

Mother’s/Legal Guardian’s Name: ______

Where will you be during school hours? ______

Phone Number: ______Pager Number: ______

Cell Phone Number: ______

Father’s/Legal Guardian’s Name: ______

Where will you be during school hours? ______

Phone Number: ______Pager Number: ______

Cell Phone Number: ______

Back up/emergency people and phone numbers who are authorized to pick up your child in case of emergency if parent(s) cannot be reached:

Name: ______Relationship: ______

Phone Number(s): ______

Name: ______Relationship: ______

Phone Number(s): ______

Please write any pertinent information that you may want us,

or any emergency agency to know in case of an emergency.

If emergency medical care is necessary, I give First Steps Children’s Center, Inc. it’s staff, and/or it’s management permission for any treatment deemed necessary.

I hereby warrant to First Steps Children’s Center, Inc. that I am entitled to legal custody and possession of my child and accordingly am authorized to place my child in your care and custody, and further am authorized to sign this emergency evacuation information form.

Parent Signature: ______Date: ______

First Steps Children’s Center

Permission/Consent Form

I hereby give my permission for my child to be cared for by First Steps Children’s Center, Inc. and for my child to use all of the play equipment and participate in all activities of the school.