Development Center Registration - Lighthouse Baptist Academy

Registration Form

Child's Name

First Last

Child's Nickname

Child's Birthday

Contact Info

Mom's Name

First Last

Dad's Name

First Last

Mailing Address

Street Address City State ZIP Code

(Mother) Email

(Mother) Home Phone

(Mother) Work Phone

(Mother) Cell Phone

(Father) Email

(Father) Home Phone

(Father) Work Phone

(Father) Cell Phone

Emergency Contact Person

First Last

Contact's Phone

Emergency Contact Person

First Last

Contact's Phone

Do you have a backup care provider?

Service Info

Beginning Date Needing Care

Hours (Monday)

Hours (Tuesday)

Hours (Wednesday)

Hours (Thursday)

Hours (Friday)

Time you plan to drop your child off?

:

Time you plan to pick up your child

:

Your Child's Health

General State of Health

Doctor's Name

First Last

Doctor's Phone Number

Dentist's Name

First Last

Dentist's Phone

Are your child's immunizations up to date?

(You will need to provide a copy of immunizations. This should include the signature of nurse or doctor who administered medications.)

Does your child have any known allergies?

Are you concerned that your child may be prone to any type of allergies?

If yes, please describe.

Does your child have any medical conditions which I should be made aware of?

Does your child have any problems with any of these?

Has your child had any of these diseases?

Does your child have any speech, hearing or visual problems?

About Your Child

Would there be any restrictions to play or activities?

Has your child ever been in child care before?

Yes
No

If yes, what type (center, family daycare, grandma etc.)

Was it a positive experience?

Why are you looking for child care?

How does your child feel about daycare and being left by his/her mommy/daddy?

Are there any recent traumatic situations the child has been exposed to such as a death in the family, divorce, new sibling, etc.?

What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc.

Are there any food restrictions?

What is your child's favorite food(s)?

What food does your child dislike?

Can your child be relied upon to indicate bathroom wishes?

What words does your child use for Bowel movements

What words does your child use for urination

What time does your child awaken?

:

What time does your child go to sleep at night?

:

Do they sleep through the night?

Does your child sleep in a bed or crib, other?

Are there any siblings? Please name them and specify ages and gender.

Has your child had experience playing with other children?

What language(s) are spoken at home?

Does your child have any security objects such as a blanket, soother, bottle, toy, etc. ?

What are your child's favorite activities, toys, books, or games?

Are there any other comments or information you would like to let me know about?

Any specific concerns?

The following people have permission to pick up/drop off my child at Lighthouse Baptist Child Development Center:

Name	Relation to Child

How did you hear about us?