Online Intake Form (Under 2 Years) | Peace & Nevaeh Childcare

Parent / Child Name and Address

Child's name (Last, First, MI) *Nickname (if any)Birthdate *First day of attendance

Parent(s) name (Last, First, MI) *Telephone number — home

Address — parent(s) (street, city, state, zip)

Health

Child has frequent colds, ear infections, colic, etc.Describe

Sleep

Current sleep scheduleLength of time on current schedule

Falls asleep easily

yesno

Mood upon awakening — describe

Takes favorite toy(s) to bed — child over age 1 year

yesno

Sleep position — child under age 1 year

Back (children under age 1 year)Side or stomach (physician statement attached)

Sleep position — child age 1 year and older

BackSide or stomach

Self-Expression

What causes your child to feel angry or frustrated?What frightens your child and how is it shown?How does your child express feelings of happiness, enjoyment, etc.?Additional comments

Miscellaneous

Child's favorite indoor toys and activities — specifyChild's favorite outdoor toys and activities — specifyList any information about your child's habits, abilities, or personality that you feel will be helpful to the staff while caring for your child.

Signature

Sign with your finger or mouse.

Printed name *Date signed *

Intake for Child Under 2 Years

Parent / Child Name and Address

Health

Meals

Sleep

Diapering / Toileting

Verbal Communication

Comforting

Self-Expression

Physical and Social Development

Miscellaneous

Signature