Child's NameChild's AddressDate of BirthChild's AgeWith whom does the child reside?Name and ages of siblings or other children living in the home.Other pertinent information you would like to share.Does your child have any special concerns (allergies, asthma, etc.)?Please indicate your expected schedule for their daily arrival and departure. The Center is open Monday-Friday from 6:30 am to 6:30 pm except for designated holidays.ArrivalDepartureBackground InformationThe purpose of securing this information about your child is to give the Center staff a better understanding your child. Your child’s care during the day is a responsibility we all share.Has your child attended another preschool or a different type of care? If yes, name and type::City/StateHow long?Does your child take any medication daily? If yes, please explain.Does your child have any food allergies?Does your child have any comforting needs, strong attachments?Types of home discipline most frequently used.Most young children are afraid of some things. Please list any fears (Examples: darkness, animals, sirens, being left alone, loud noises, crying, etc.).Please describe your child’s favorite activities.Favorite recreational pastime.Does your child have any habits, needs, schedules, or irritations you feel we should know about in attempting to personalize our approach? If so, please describe.Child's Developmental HistoryDoes he/she have difficulty speaking?Does he/she use any special words to describe his/her needs?Do you feel your child will adjust easily to the Center?How well does he/she get along with other children?Does your child have any needs requiring special attention?Do you have any special request?We encourage parent participation. If you have any skills or hobbies you would like to share with the children or staff, please let us know.Thank you for helping us to get to know your child better. We want you to have a terrific experience here, and having a successful Clubhouse experience will depend upon your partnership with your child’s teacher. If you have any concerns at all, please address those concerns directly with the teacher. We want to provide your family with a high level of service and can only do this if we have feedback from you. Our teachers are professionals and want the best for your child. The Center reserves the right to discharge a child, after a trial period, who does not adjust to the Center’s program. I have shared all important information regarding the care of my child including developmental and behavioral concerns.Signature of Parent or Legal GuardianDate MM slash DD slash YYYY
