I. Registration/Child’s History

Child’s Name____________________________________________ DOB__________________

First Middle Last

Address_______________________________________________________________________

City_____________________________ Zip________________ Phone____________________

Mother or Guardian______________________________________________________________

First Maiden Last

Father or Guardian______________________________________________________________

First Middle Last

Names of Siblings Age School/Grade

_______________________________ _______ _____________________________

Parent’s Employment

Mother:

Department_________________________ Phone__________________ Hours____________

SS#___________________________ DL#___________________________

Father:

Department_________________________ Phone__________________ Hours____________

SS#___________________________ DL#___________________________

Marital Status of Parents

q Living Together	q Stepmother: How Long? ___________
q Separated: How Long? __________	q Stepfather: How Long? ____________
q Divorced: How Long? ___________

Remarks:______________________________________________________________________

Custody/Visiting Arrangements_____________________________________________________

_____________________________________________________________________________

If child is adopted: Age at adoption_______ Does child know he/she is adopted?______

Members of extended family who live in home (include relationship to child and age)

_____________________________________________________________________________

Does child have room alone?_______ Is shared room, with whom?__________________

Who has cared for child other than parents?__________________________________________

_____________________________________________________________________________

Has child had other group experience? (Specify)_______________________________________

_____________________________________________________________________________

Other children in Home:

Name Age Relationship

_______________________________ _______ _____________________________

Other Relatives/Persons in Home:

Name Relationship to Child

_______________________________ _____________________________

Do you have any family pets? Yes No

_____________________________________________________________________________

Is there any evidence of food or other allergy? Yes No

Explain: __________________________________________________________________

____________________________________________________________________________

Are there any foods your child cannot eat?__________________________________________

_____________________________________________________________________________

Is a language other than English spoken at home? Yes No

Which language is dominant?______________________________________________________

Does the child use one hand in preference to the other? Yes No

Right Left

II. Personal Information

1) Has the child moved since birth? Yes No

When___________________________ Where____________________________________

2) Has the child traveled? Yes No

Where?_________________________________________________________________

___________________________________________________________________________

3) Has the child traveled by: Boat Train Airplane Bus Automobile

4) What problems, if any does the child experience when traveling?______________________

___________________________________________________________________________

5) Child’s pattern for napping and going to bed at night________________________________

___________________________________________________________________________

III. Authorized Release Form

The following individuals have permission to transport my child __________________________

to and from Children’s Nook Day Care: (child’s name)

Name____________________________________________

Relationship to Child________________________________

Home Address_____________________________________ Home Phone__________________

Work Address_____________________________________ Work Phone__________________

Name____________________________________________

Relationship to Child________________________________

Home Address_____________________________________ Home Phone__________________

Work Address_____________________________________ Work Phone___________________

Name____________________________________________

Relationship to Child________________________________

Home Address_____________________________________ Home Phone__________________

Work Address_____________________________________ Work Phone__________________

Name____________________________________________

Relationship to Child________________________________

Home Address_____________________________________ Home Phone__________________

Work Address_____________________________________ Work Phone__________________

IV. The following individuals are FORBIDDEN to transport my child________________ to and from Children’s Nook Day Care (child’s name)

Name___________________________________ Relationship to Child_____________________

I will notify Children’s Nook Day Care of any changes in this respect, and I will update this Release Form when necessary.

Signature_____________________________________________ Date____________________

(Mother or Legal Guardian)

Signature_____________________________________________ Date____________________

(Father or Legal Guardian)

V. Emergency Notification Form

In the event my child ________________________________ is accidentally injured, becomes suddenly ill, or is otherwise in need of assistance from outside the childcare facility, Children’s Nook is authorized to notify the following individuals in the even that I (we) cannot be reached. These individuals are authorized to remove my child from Children’s Nook if necessary.

Name____________________________________________

Relationship to Child________________________________

Home Address_____________________________________ Home Phone__________________

Work Address_____________________________________ Work Phone__________________

Name____________________________________________

Relationship to Child________________________________

Home Address_____________________________________ Home Phone__________________

Work Address_____________________________________ Work Phone__________________

Name____________________________________________

Relationship to Child________________________________

Home Address_____________________________________ Home Phone__________________

Work Address_____________________________________ Work Phone__________________

Name____________________________________________

Relationship to Child________________________________

Home Address_____________________________________ Home Phone__________________

Work Address_____________________________________ Work Phone__________________

I will notify the Nursery of any changes in this respect, and I will update this Emergency Notification Form when necessary.

I am (we are) the person(s) legally responsible for the care of the above-names child.

Signature_____________________________________________ Date____________________

(Mother or Legal Guardian)

Signature_____________________________________________ Date____________________

(Father or Legal Guardian)