Regulations for licensed child care facilities require this information to be on file to address the needs of children while in care.
CHILD'S NAME__________________________________________________________DATE OF BIRTH___________________
Any speech difficulties?_______________________________________________________________________________________
Special words to describe needs:________________________________________________________________________________
Any known complications at birth?______________________________________________________________________________
Serious illnesses and/or hospitalizations:__________________________________________________________________________
Special physical conditions, disabilities:__________________________________________________________________________
Allergies i.e. asthma, hay fever, insect bite/medicine/food reactions:_____________________________________________________
_________________________________________________________________________________________________________
Regular medications:________________________________________________________________________________________
Special characteristics or difficulties:____________________________________________________________________________
Favorite foods:________________________________________________________Child eats with hands____spoon____fork____.
Foods refused:______________________________________________________________________________________________
How does child indicate bathroom needs (include specific words)?________________________________________________
Is child ever reluctant to use the bathroom?_______________________________________________________________________
Does child have accidents?____________________________________________________________________________________
Does child become tired or nap during the day (include when and how long)?_____________________________________________
When does child go to bed at night?______________________________and get up in the morning?___________________________