Family Child Care Enrollment Packet Face Sheet Page 4
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8DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION
Regulations for licensed child care programs require this information to be on file to address the needs of
children while in care.
CHILD'S NAME _______________________________________
DATE OF BIRTH _____________
*Note: Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child.
DEVELOPMENTAL HISTORY
Age began sitting ________ crawling ______ walking _________ talking ____________
*Does your child pull up? ________ *Crawl? ______ *Walk with support? _______
Any speech difficulties?______________________________________________________________________
Special words to describe needs ______________________________________________________________
Language spoken at home _______________________ *Any history of colic? __________________________
*Does your child use pacifier or suck thumb? _____________ *When? ________________________________
*Does your child have a fussy time? ____________________ *When? ________________________________
*How do you handle this time? ________________________________________________________________
HEALTH
Any known complications at birth? ____________________________________________________________
Serious illnesses and/or hospitalizations: _______________________________________________________
Special physical conditions, disabilities: ________________________________________________________
Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions:
________________________________________________________________________________________
________________________________________________________________________________________
Regular medications: _______________________________________________________________________
EATING HABITS
Special characteristics or difficulties: ___________________________________________________________
*If infant is on a special formula, describe its preparation in detail _____________________________________
________________________________________________________________________________________
Favorite foods: ____________________________________________________________________________
Foods refused: ____________________________________________________________________________
* Is your child fed held in lap? ______________
High chair? ____________________
* Does your child eat with Spoon? _____________________ Fork? ______________ Hands? _____________
TOILET HABITS
*Are disposable or cloth diapers used? _________________
*Is there a frequent occurrence of diaper rash? ____________________________
*Do you use: baby oil ________ powder ______________
lotion ________________ Other _____________
*Are bowel movements regular? ________________ how many per day? _______________
*Is there a problem with diarrhea? _______________ Constipation? ____________________
*Has toilet training been attempted? _____________
*Please describe any particular procedure to be used for your child at the program
__________________________________________________________________________________________
What is used at home? Potty chair? _______ special child seat? _________ regular seat? _________
How does your child indicate bathroom needs (include special words): _________________________
Is your child ever reluctant to use the bathroom? ___________________________________________________
Does the child have accidents? _________________________________________________________________
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FCCEnrollmentPacket20110406
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