Infant/toddler Development And Routine Form Page 2
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1
2Play
What is your child's favorite toy/object or song?
Does your child enjoy playing with others?
Does your child do well playing alone?
What activities and toys does your child enjoy?
Health
Does your child have any health problems?
If yes, explain:
Does your child take any medication(s) regularly?
If yes, please list:
Does your child have a chronic health condition or specific health needs?
Please be specific:
Does your child have frequent
Ear infections
Diarrhea
Constipation
Do you have any concerns about your child's health?
If yes, explain:
Children in group care may become ill with colds, viruses, etc. several times per year. At times, we are required to ask parents to keep their children
out of child care until treatment begins or there are no symptoms. Please see our Exclusion policy.
GENERAL DEVELOPMENT
Was your child:
Full Term
Premature
Is your child adopted?
If yes, does he/she know?
Describe complications (if any) during pregnancy, the birth process or following birth:
Describe any physical or emotional limitations your child has including diagnosis & treatment:
Are there any other adults providing services to your child at this time?
Yes
No
If yes, explain:
Do you have any concerns about your child's:
Hearing and/or vision?
Speech and language development?
Ability to move?
Overall development?
SOCIAL AND EMOTIONAL DEVELOPMENT
Has your child ever been in group child care?
Yes
No
If yes, type of setting:
How does your child respond in group situations:
What can we do to help your child adjust to child care:
How would you describe your child's temperament and personality:
How do you comfort your child:
Does your child use a special comforting item: (blanket, stuffed animal, doll)
Does your child fear certain things:
How is your child disciplined:
What works best when you discipline your child:
Do you have any questions or concerns about your child's social/emotional development or behavior:
If yes, please explain:
What educational/developmental experiences would you like us to emphasize with your child (for example, language development, social relationships,
kindergarten readiness skills, physical or self-help, etc):
Signature of Parent or Guardian
Date
CCD-ITRoutine - REV 06/2012
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