Registration Form
Child's Name
First
Last
Child's Nickname
Child's Birthday
MM slash DD slash YYYY
Contact Info
Mom's Name
First
Last
Dad's Name
First
Last
Mailing Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
MM slash DD slash YYYY
Hours (Monday)
Hours (Tuesday)
Hours (Wednesday)
Hours (Thursday)
Hours (Friday)
Time you plan to drop your child off?
:
Hours
Minutes
AM
PM
AM/PM
Time you plan to pick up your child
:
Hours
Minutes
AM
PM
AM/PM
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?
Constipation
Convulsions
Diarrhea
Fainting Spells
Frequent Colds
Frequent Ear Infections
Frequent Sore Throats
Lice
Ringworm
Skin Rash
Soiling
Stomach Upsets
Urinary Problem
Worms
Has your child had any of these diseases?
Asthma
Bronchitis
Chicken Pox
Diabetes
Heart Disease
Hepatitis
Impetigo
Measles
Mumps
German Measles
Polio
Scarlet Fever
Tuberculosis
Whooping Cough
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?
:
Hours
Minutes
AM
PM
AM/PM
What time does your child go to sleep at night?
:
Hours
Minutes
AM
PM
AM/PM
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?