Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Parent's Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Has your child been in a daycare or other care facility before? *

Yes

No

Are these days consistent? *

Yes

No

Are your child’s immunizations up to date? *

Yes

No

Are you able to pick up the child in case of illness, accident, or emergency? *

Yes

No

Do you have someone who can also be called in case of illness, accident, or emergency? *

Yes

No

Do you have back-up care? *

Yes

No

Are you willing to sign a contract? *

Yes

No

Is your child fully toilet trained? *

Yes

No

Does your child ask to go to the bathroom? *

Yes

No

Does your child need help going to the bathroom? *

Yes

No

Are you OK with messy play and art? *

Yes

No

Does your infant take a bottle?

Yes

No

Do you use breastmilk or formula?

Breastmilk

Formula

Mix of both

Neither

Can you provide enough milk for your child’s daily need, plus an extra four ounces in case of emergency or spills?

Yes

No

Do you use cloth or disposable diapers?

Cloth

Disposable Diapers

ABC Home loves to incorporate new ideas, cultures, and skills into the Home and offers parents the option to add to our enrichment. How would you like to participate in our program? *

I'd like to share a special interest/skill

I'd like to assist with classroom activities

I'd like to join for special events

Other