Just for Kids Preschool

Enrollment Packet
Please fill out these forms completely. Any questions that do not apply to your child please put
N/A. If you need assistance please call 352-222-111 or schedule and appointment.

General Information
Date of admission: _____________________ Age at Admission: _______________
Date of Discharge: __________________ Reason for discharge: __________________________

Childs full name: ___________________________________________

Date of birth: _____________ Telephone number: ___________________
Address______________________________ City: ___________________ zip: ______________

Name of Parent(s) or Guardian(s): _________________________________________

Home Address (if different): _____________________________________________
Email Address: _____________________________
Business Phone number___________________________________
Name of work: ______________________________________

Emergency Contact/ Authorized Pick-up

In the event of an emergency, and I cannot be reached one of these individuals will be
contacted. I also authorize these individuals to pick-up my child from the facility. Please notify
your childs teacher at drop off.
Name: __________________________________ Name: ____________________________
Phone number____________________________ Phone Number: _____________________
Address_________________________________ Address____________________________
_______________________________________ __________________________________

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Anticipated Days and Times of Attendance
Days Program

Monday Half day (9am- 12pm)

Tuesday Full day (9am- 3pm)
Wednesday Extended Care (6am-8:30am or
Thursday 3pm-6pm)
Friday

Parent Handbook
I acknowledge that I have received the parent handbook.
Parent/Guardian signature: __________________________________________

Childs Physician/health care professional

Name: _______________________________
Phone number: ________________________________

Please note any special health information we need to know about your child. (Ie: allergies,
special diets, chronic health conditions, special limitations)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

School Age Only

Name of School: ______________________ School Phone: ____________________
Anticipated transportation (bus, walk, etc...): _____________________________

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History and Background Information

Childs Name: _________________________ Date of birth: ____________________

Important information
Any speech difficulties? ______________________________
Special words to describe needs: ____________________________
Does your child use a pacifier? ____________ suck thumb _________________
Infants and Toddlers- Crawl________? Pull up to stand___________?
Walk with help______?

Allergies (asthma, medicines, insect bites, food)

______________________________________________________________________________
______________________________________________________________________________
Regular medications_____________________________________________

Eating Habits
Special characteristics/difficulties: ________________________________________
Special formula preparation:
______________________________________________________________________________
Favorite foods: ________________________________________________________
Food refused: _________________________________________________________

Does your child eat with a fork spoon hands

Where is your child typically fed? ___________________________________________

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Toilet Habits
Disposable or cloth diaper? _________________________
Has toilet training been attempted? ___________________________
Is your child ever reluctant to use the bathroom? _____________________________
Does your child have accidents? __________________________________

Relationships
How would you describe your child?
_________________________________________________________________________
Does your child have any fears?
_________________________________________________________________________
How do you comfort your child?
________________________________________________________________________
What discipline management is used at home?
________________________________________________________________________
What would you like your child to gain from his/her experience at childcare?
_________________________________________________________________________

Is there anything else we should know about your child?

______________________________________________________________________________
______________________________________________________________________________

Parent/guardian signature_____________________________ Date: _______________

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 Emergency Information
Instructions to reach parent or guardian
1.____________________________________________________________________________
2.____________________________________________________________________________

Contact information of Physician

Name: _____________________________________
Phone number_______________________________
Address____________________________________

Emergency Contact Persons

1.____________________________________________________________________________
Name, phone number, address

2.____________________________________________________________________________
Name, phone number, address

Emergency Medical treatment

I hear by give __________________________ permission to administer basic first aid and/or

(name of educator/assistant)

CPR to my child _________________________________ and/or take my child to a hospital if I

(name)
cannot be reached.

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Resources:
http://www.mass.gov/edu/docs/eec/licensing/forms/family-child-care/family-child-care-
enrollment-packet.pdf

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