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23202 W. Lee Highway Philadelphia, TN  37846 (865) 458-1663                                    

101 Harmon Lane Lenoir City, TN 37771 (865) 986-3237

Fax #:  (865) 986-0850

Full Name of Child:_________________________________________________________

Date of Admission:_______/________/_________

Child's DOB:_____________  Name the child goes by:___________________________

Is the child related to the primary caregiver?___No  ____Yes-Relationship____________

Child's School (if applicable)_________________________________________________

 Address of School:________________________________________________________

Phone Number of School:___________________________________________________

Are the child's immunization records housed at the above school:  ____Yes  _____ No

If no, list the school where they are housed:_______________________________________________________________________________

            Name                                           Address                                            Phone

Name of Agency:___________________________________________________________

Agency Address:___________________________________________________________

Parents/Custodial Parents:

Mother's Name:____________________________________________________________

Home Address:____________________________________________________________

City____________________________ State____________________ Zip_____________

Home Phone:(_____)______________ Cell Phone:(_____)________________________

Employment:____________________________________________________________

Work Address:___________________________________________________________

City__________________________ State_____________________ Zip_____________

Work Phone:_______________________ Work Hours___________________________

Father's Name:___________________________________________________________

Home Address:___________________________________________________________

City___________________________ State___________________ Zip_______________

Home Phone:(_____)____________________ Cell Phone:(______)__________________

Employment:______________________________________________________________

Work Address:_____________________________________________________________

City_________________________ State____________________ Zip_________________

Work Phone:________________________ Work Hours:___________________________

TRANSPORTATION PLAN:

Please list any other adults to whom your child may be released or are authorized to provide transportation for your child.

_________________________________________________________________________

_________________________________________________________________________

Will the child be transported by the agency? ____No  ______ Yes  If yes, check all that apply:

______to school    _______from school     _______ field trips only-with prior written permission for each off-site activity

SCHOOL INFORMATION:

My child attends_________________________school at________________________________

(address)  and my child's shot record is on file at________________________ school.  I give Kiddie Kingdom permission to transport my child to and/or from school.

EMERGENCY CONTACT INFORMATION:

1.)  Name of person, other than the child care provider, authorized to act for parent in an emergency.

Name:__________________________________________ Phone:____________________________

Home Address:_____________________________________________________________________

Place & Address of Employment/School:________________________________________________

__________________________________________________________________________________

Work Phone:___________________________ Work Hours:_________________________________

Alternate Phone Numbers (Cell):_______________________________________________________

2.) Name of person, other than the child care provider, authorized to act for parent in an emergency.

Name:____________________________________________ Phone:___________________________

Home Address:______________________________________________________________________

Place & Address of Employment/School:_________________________________________________

___________________________________________________________________________________

Work Phone:_____________________________ Work Hours:________________________________

Alternate Phone Numbers (Cell):_________________________________________________________

3.)  Name of person, other than the child care provider, authorized to act for parent in an emergency.

Name:______________________________________________ Phone:__________________________

Home Address:_______________________________________________________________________

Place & Address of Employment/School:__________________________________________________

____________________________________________________________________________________

Work Phone:__________________________________ Work Hours:_____________________________

Alternate Phone Numbers (Cell):__________________________________________________________

PHYSICIAN CONTACT INFORMATION:

Name of Physician:____________________________ Phone:_________________________________

Address:____________________________________ City______________ State_____ Zip__________

BACKGROUND INFORMATION:

Other Children in the Family:                  Date of Birth:                             School:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

___________________________________________________________________________________

EXPERIENCES WITH OTHERS:

What are some of the ways the child plays at home?__________________________________________

Does he/she play with children from other families?_______ How?_______________________________

Does he/she react when he/she does not get his/her own way?_________________________________

_____________________________________________________________________________________

Is the entire family together for any time during the day?_______________________________________

EATING HABITS:

At what time does the child eat breakfast?________Lunch?____________ Dinner?_________________

Between-meal Snacks?________ Does the child feed himself/herself?___________________________

What is the child's general attitude toward eating?___________________________________________

If the child refuses to eat, how is this handled and by whom?___________________________________

_____________________________________________________________________________________

Food Favorites:________________________________________________________________________

Food Dislikes:_________________________________________________________________________

Food Allergies:_________________________________________________________________________

If the child is an infant, use a seperate sheet for information about the formula, bottle schedule, etc.


SLEEP HABITS:

Has own room:___________ Shares room with ______ Other Children     _______ Parents

At night sleeps from ___________ to ______________ Average hours of sleep per night:_____________

Naps from __________ to _____________ Average hours of naps:____________________________

Attitude toward going to bed:_____________________________________________________________

If there is difficulty, how is this handled?____________________________________________________

Habits associated with going to bed?______________________________________________________

Is bed wetting an issue?_______________________ At nap time?__________ At night?____________

If yes, how is the situation handled?______________________________________________________

TOILET HABITS:

Time at which child is taken to the bathroom?_______________________________________________

Can the child take themselves?__________________ Time of bowel movement?___________________

Regular?________________ Constipated?____________________ Does the child tell you when he/she needs to go willingly?_____________________ Can he/she manage his/her clothes at the toilet?______

What words does he/she use for Urinating:____________________ Bowel Movement_______________

SPEECH AND PHYSICAL GROWTH:

The child talks:_____ Well ______ Fairly Well  ________Not Very Well    _______ Not at all

Does anyone read to the child?__________ How regularly?____________ At what age did the child creep?______________ Crawl?_______ Walk?______________ Which of the following words would you use to describe the child (Check all that apply):_____active  _____quiet  ______thin  ______average weight ____ heavy  _____tall  _____average height  _____short  ____ friendly  ______ unfriendly

Is there any other information you think we should have about the child?__________________________

______________________________________________________________________________________

______________________________________________________________________________________

ONGOING MEDICAL CARE:

Does the child have any medical diagnosis that requires ongoing care?___________________________

_____________________________________________________________________________________

If yes, explain what type of care is administered at home and by whom?__________________________

_____________________________________________________________________________________

Are you requesting that this care be provided at the facility? ______Yes   _______No  If yes, describe the care required?_______________________________________________________________________

______________________________________________________________________________________

(Request a doctor's statement for any specified requests for care at the facility).

MEDICAL HISTORY: (Please check any and/or all that apply)

Measles_____________ Mumps____________ Chicken_________________ Whooping Cough________

Asthma______________ Tonsillitis__________ Ear infections_________Free Bleeder_______________

Meningitis____________ Seizures___________ Reaction to TB test______________________________

ALLERGIES:___________________________________________________________________________

Is there any evidence of: (Please check any and/or all that apply)

Hearing Problems_________ Vision Difficulties_____________ Speech Difficulties__________________

Kidney Problems__________ Comments____________________________________________________

Hospitalizations:________________________________________________________________________

Serious Illnesses_______________________________________________________________________

Medications taken Regularly______________________________________________________________

PARENT DECLARATIONS:

I received a summary of licensing requirements.  I do hereby authorize emergency medical care for my child (a limited power of attorney may be required for military dependents).  I visited the facility prior to enrolling my child.  Pre-enrollment visit date:___________________.  I received a copy of the child care facility's policy statement or handbook, and payment contract, and I have signed their copy, verifying by receipt my understanding and agreement of their content.  I authorize the agency to transport my child as specified in the transportation plan section (see page 1).

___________________________________________________  _________________________________

Signature of Parent(s)/Guardian(s)                                                            Date

Date of Child's Withdrawal:____________ Reason for withdrawl:_________________________________

This form/information shall be maintained for one year after date of  disenrollment.

Information on this form shall be updated annually or as needed to ensure the protection of the child.

Date of last update with parent's initials:

______________________________________________________________________________________

______________________________________________________________________________________