SORRY! FORM NOT WORKING, UNDER CONSTRUCTION:Mother's Name: Telephone:  E-Mail:

Father's Name: Telephone:   E-Mail:

Child's Name : and Birth Date:  

Check here if more sisters or brothers :

New Baby :  Due Date: Back to Work Date:

Requested First Day of Care:

Parents Address :

Places of Employment:

Mother : Hours: From:    To:

Father:  Hours: From:    To:

Type of Care Looking For:                        Permanent Temporary FullTime PartTime HalfDays Hourly     Days of Care:                   Mon_Fri Evening Weekends Other

Drop Off Time:        Pick Up Time:   

Will Your Child Eat Breakfast at Daycare?

Kim's Kids Daycare

TODDLERS:

Is Your Child Potty-Trained? When?

What are their normal nap times?

How do you handle discipline at home?

Does your child have any allergies?  Fears?

What are is favorite foods? Toys? Animal?

Do You Read to your child at home?   Favorite Books?

INFANTS:

Bottle Fed   Breast Fed   Weaned    /When?

Types of Formula Tried:

Tried Solid Foods    Tried Table Foods   Any Allergies?

Light Sleeper   Heavy Sleeper    How many naps per day? How Long?

Are there any special instructions concerning Child Care, Medications, Religious Beliefs, or Diet that I should be aware of?

What are your expectations of Family Home Child Care?