Infant Enrollment Intake Form printable pdf download

Infant Enrollment Intake Form

Child’s Name: ___________________________ Date of Birth:________________ Gender:

Eating

Is your child on any special diet? ____Vegetarian ____ovo-lacto ____vegan ____other

Does your child have any food allergies? _______ If yes, please describe _____________________________

__________________________________________________________________________________________

Would you allow us to post a photo of your child to alert all staff to his/her allergy?

Yes

What does your child use to drink?

____bottle

____ sippy cup ____ regular cup

____nursing

_____other:___________________

How often does your child eat? _______________________________________________________________

Has your infant started on any other foods besides formula or breast milk? _____________________________

_________________________________________________________________________________________

Sleeping

Does your child nap?

Yes

How many times per day? _________ How long?____________

Does your child sleep with a special blanket, toy or “lovey”, or pacifier?

Yes

Are there specific bedtime routines at home? ____________________________________________________

__________________________________________________________________________________________

Where does your child sleep at home

?_______________________________________________________________________

Toileting

Does your child use diapers?

Yes

____Cloth ____Disposable ____Pull ups

If cloth, remember that we are unable to launder diapers and they will be bagged and sent home un-rinsed and

un-emptied.

Are there any specific ointments or lotions your family uses: _______________________________

Development

Do you have any concerns about your child’s development?

Yes

____Hearing ____Vision ____Language ____Gross Motor ____Fine Motor ____Social ____Other

__________________________________________________________________________________________

Is there anything about your child's birth that you would like to share?__________________________

__________________________________________________________________________________________

What is your child’s primary spoken language? ___________________________________________________

Are there other languages being used with your child_______________________________________________

Infant Enrollment Intake Form