Form LS-202-09-24-18 Page 1 of 7 CHILD ENROLLMENT FORM (Continued)

CHILD ENROLLMENT FORM

This form enrolls your child at the Little Stars Early Learning Center. You will provide detailed information on this form that will allow Little Stars personnel to tailor their child care to your child’s specific needs. Please be as accurate and complete as you can with the information you provide on this form.

Child Information Last Name: First Name: Date of Birth (mm/dd/yyyy):

Street Address: City: State: Zip:

Phone: Start Date (mm/dd/yyyy):

Days Attending X >> Mon Tue Wed Thu Fri

Days & Hours From>> Attending Between (7 AM & 6 PM) To>> Mother’s Information Last Name: First Name: Middle Name:

Street Address: City: State: Zip:

Home Phone: Work phone (Not required if not working): Mobile Phone:

Phone Number where parent can be reached during program hours: Place of Employment:

Father’s Information Last Name: First Name: Middle Name:

Street Address: City: State: Zip:

Home Phone: Work phone (Not required if not working): Mobile Phone:

Phone Number where parent can be reached during program hours: Place of Employment:

Marital Status of Parents Years: Years: Married Divorced Separated Single Months: Months: Sibling Information Last Name: First Name: Date of Birth (mm/dd/yyyy):

Last Name: First Name: Date of Birth (mm/dd/yyyy):

Form LS-202-09-24-18 Page 1 of 7 CHILD ENROLLMENT FORM (Continued)

Other Members of Household Information Last Name: First Name: Age (Years):

Last Name: First Name: Age (Years):

Emergency Information Last Name: First Name: Relationship to Child: Pick-up and/or Drop-off Person #1 Last Name: First Name: Relationship to Child: Pick-up and/or Drop-off Person #2 Last Name: First Name: Relationship to Child:

Authorized Street Address: City: State: Zip: emergency pickup person #1: Home Phone: Work Phone (If working): Cell Phone:

Last Name: First Name: Relationship to Child:

Authorized Street Address: City: State: Zip: emergency pickup person #2: Home Phone: Work Phone (If working): Cell Phone:

Last Name: First Name: Non-Custodial Court Decision on File:: NOT authorized to pickup person #1: Yes No Last Name: First Name: Non-Custodial Court Decision on File:: NOT authorized to pickup person #2: Yes No

Note: A copy of the non-custodial court decision must be on file at Little Stars Early Learning Center, LLC in order for the program NOT to release a child to his/her non-custodial parent/relative.

Health Care Provider Information Last Name: First Name: Telephone Number:

Doctor: Street Address: City: State: Zip:

Hospital/Clinic Name: Telephone Number: Hospital / Clinic: Street Address: City: State: Zip:

Last Name: First Name: Telephone Number:

Dentist: Street Address: City: State: Zip:

Form LS-202-09-24-18 Page 2 of 7 CHILD ENROLLMENT FORM (Continued)

Health History

Does your child Yes have allergies?: Describe>>

Does your child take Yes any medications?: List>>

Does your child have Yes any disabilities?: List>>

Has your child been seen Yes by a medical specialist?:Specify who/what>> Does your child have any AIDS HIV Hepatitis A or B Malaria Other ↓ Describe contagious illness that Yes could impact the children or staff?: Check all that apply>>

Does your child have any Yes other illnesses / diseases?: Specify>>

Does your child have any Yes speech difficulties?: Explain>> Does your child have Yes frequent colds, sore throat, or infections?: How Often?>>

Has your child ever been Yes hospitalized?: Date(s) & Reason(s)>> Has your child ever had : Yes any serious accidents or poisonings?: Explain>>

Has your child been to Yes the Dentist?: Explain>>

Has your child had his/her Yes vision checked?: What was the Result?>>

Has your child had his/her Yes hearing checked?: What was the result?>>

Convulsions or seizures Describe>>

Check all Premature Birth of the Describe>> following Trouble conditions breathing at right at birth Describe>> that apply to Head injury your child: Describe>>

Birth injury or defect Describe>>

Form LS-202-09-24-18 Page 3 of 7 CHILD ENROLLMENT FORM (Continued)

Feeding/Eating

Does your child have Yes any food allergies?: Describe>>

Does your child have Yes any eating difficulties?: Explain>>

Does your child refuse Yes to eat any foods?: Which foods?>> Does your child eat with any of Spoon Fork Hands these? (Check all that apply):

Does your child have any Yes dietary restrictions?: Specify>>

Does your child have any Yes favorite foods?: Specify>>

Is your child usually hungry Yes Is your child hungry Yes at mealtimes?: between meals?: Breakfast Lunch Snack Supper What time does your child normally eat?:

Vegetarian Vegan Other Does your child have a Yes dietary preference?: Describe>>

Item▼ / Qty► Juice (Oz) Food (Cups) Milk/Formula Breakfast Describe your child’s eating amounts (Enter 0 if not applicable): Lunch

Snack

Infant How is your child fed? Type of Bottle: Type of Nipple: Formula: Breast Bottle (Check all that apply): ______

Does your child have Yes to be burped?:

Toileting Bowel Movements/Day: Appearance of stool: Bathroom Visits/Day: Bowel movement & bathroom frequency and appearance: Does your child Infant / have diaper Yes Toddler rash often?: How is it treated?>> : Is your child Yes

toilet trained?:For how long?>> What was the Toddler / difficulty of potty Easy Difficult Preschool training your child?: Is your child able to indicate Yes when he/she need to use the toilet?:

Form LS-202-09-24-18 Page 4 of 7 CHILD ENROLLMENT FORM (Continued)

Toileting (continued) Does your child use a Yes potty chair?: What words does your child use for urination or Toddler / bowel movement?: Preschool Is your child afraid of the Yes bathroom?: Does your child have toileting Yes accidents?: Child’s reactions>> Sleeping

From: From: From: Describe your child’s Night Morning Afternoon sleep schedule: Time: Nap Nap To: To: To: Does your child have a pacifier, blanket or Yes special toy for sleeping?: Describe >> Do you have a specific way of helping your child Yes go to sleep?: Describe?>>

Does your child cry when Yes falling asleep?: Describe methods you use>> Describe your child’s mood when awakening: Social Involvement

Describe your child’s natural nature: Friendly Aggressive Shy Withdrawn Other

Will your child know Yes anyone at Little Stars?: What age group does your child prefer to play with? Infant Toddler Preschool School-Age Adult (Check all that apply):

Identify the words that best Anxious Confident Cooperative Fearful Follower Friendly describe your child (Check all that apply): Insecure Leader Loving Responsible Self-Reliant Shy Describe how your child reacts and adjusts to babysitters, new people, or new situations?: Describe how your child reacts and adjusts to new people and places?:

Describe how your child Likes to share Does not share handles sharing: Has your child had experience playing with Yes other children?: Describe any difficulties>> Describe your child shows his/her feelings:

Form LS-202-09-24-18 Page 5 of 7 CHILD ENROLLMENT FORM (Continued)

Social Involvement (continued) Describe what makes your child angry or upset:

Fears & Anxieties>> Describe any fears or anxieties that your child has and what behavior guidance methods work best with you child Best working behavior guidance methods>> Describe how behavior guidance is handled at home:

Does your child have any Yes behavior concerns?: Describe>> Describe how you handle or prevent these concerns:

Hours your child spends each day doing these activities: Playing Alone (Excluding TV):______Hrs/Day Playing Outside:______Hrs/Day Does your child have things / situations they Yes need extra help with: Describe>> Ties Washing Dressing Drinking Feeding Toileting Other Identify the things your child Shoes Hands can do by himself/herself:

Developmental History What language is spoken in your home?:

What language(s) do you or your child speak?

Does your child have a Yes favorite toy?: Describe?>>

Does your child have a Yes favorite Activity?: Describe?>>

Identify the things your child Blocks Clay Easel Painting Finger Painting has experience with (Check all that apply): Glue Scissors Water Play

Being read to? Yes No Climbing Yes No

Identify the things your child likes: Listen to music? Yes No Tri-cycling or bicycling Yes No

Playing outdoors Yes No

Has your child been in a group child care setting previously?: Yes No Check the activities that your toddler / pre-school child can perform and Sit: Crawl: Walk: Talk: enter the earliest month performed. What do you do to comfort your child?:

Form LS-202-09-24-18 Page 6 of 7 CHILD ENROLLMENT FORM (Continued)

Special Interests What interests or fascinates your child?

What activities does Indoors► your child prefer most often?: Outdoors►

Specify any special abilities that your child may have:

Is your child allowed to be around Yes No animals? (If No explain):

Do you own an animal?: Yes What kind?>> Is your child able to participate in Holiday activities held at the center? Yes No (If No specify excluded holidays): Identify any cultural practices or holidays that you would like us to know about: Identify any special benefits or learning experiences that you wish for your child to have during his/her experience with us: Please note any additional information about your child that will help staff know how to better care for him/her:

Signatures Mother Signature: Date (mm/dd/yyyy)

Father Signature: Date (mm/dd/yyyy)

Little Stars Director Signature: Date (mm/dd/yyyy)

Little Stars Treasurer Signature: Date (mm/dd/yyyy)

INFORMATION BELOW FILLED IN BY LITTLE STARS

Date First Week Tuition(s) received: Issued Sign-In Code:

Date Health Care Summary(s) received: Fingerprint Scan-In Date (If applicable):

Date Immunization Form(s) received: Name of LSELC Approver:

Form LS-202-09-24-18 Page 7 of 7