The Academy of Development

Enrollment Form

Child’s information: Date of Enrollment______________

Child’s full name:______________________________________________________________

Nickname:__________________________________ Birthdate:_______________________

Circle Days To Attend: Monday Tuesday Wednesday Thursday Friday

Between what hours will your child(ren) be in our care on these days?____________________

Parents Information:

Mother’s/guardian’s name:___________________Father’s/guardian’s name:______________

Home Address:_______________________ Home Address:_____________________

___________________________________ ______________________________________
city state zip city state zip

Home Phone:_________________________ Home Phone:___________________________

Cell Phone:___________________________ Cell Phone:____________________________
Work Phone:__________________________ Work Phone:___________________________

Work Address:________________________ Work Address:_________________________

____________________________________ _____________________________________
city state zip city state zip

Parents Marital Status: Married separated divorced single widowed

Child lives
with_________________________________________________________________
If Divorced, Who has legal Custody?_______________________________________________
May The Non Custodial Parent Pick Up Child?___________________

Transportation Plan: To insure the safety of your child, please list other adults to whom your
child may be released or who are authorized to provide transportation for your child.

Name & Phone________________________________________________________________

Name & Phone________________________________________________________________
Name & Phone________________________________________________________________
Name & Phone________________________________________________________________

Background Information:
other children in the family Birthdate School
______________________ _________ _____________________
________________ _________ ____________________
_________ ________________________
______________________ _________
________________________
______________________ _________
________________________
______________________ _________ ____________________

Emergency Contacts Other Than Parents: List persons authorized to act for
parents/guardians in an emergency other than The Academy staff.

Name &
Phone_________________________________________________________________

Address____________________________________________________________________
city state zip
Place & Address
of Employment/School:__________________________________________________________
city state zip
work phone__________________________________ work hours____________________

Name &
Phone_________________________________________________________________

Address_____________________________________________________________________
city state zip
Place & Address
of Employment/School:__________________________________________________________
city state zip

work phone__________________________________ work hours____________________

Name &
Phone_________________________________________________________________

Address_____________________________________________________________________
city state zip
Place & Address
of Employment/School:__________________________________________________________
city state zip
work phone__________________________________ work hours____________________

Physician Information:
Name and Phone of child’s physican_______________________________________________
Address_____________________________________________________________________
city state zip
Are your child's immunizations up to date? _________ (Please attach a copy of immunizations.
On the state approved form.). An immunization record must be on file prior to attending.
Experiences with Others:
What are some of the ways the child plays at home?__________________________________

Does he/she play with children from other families?____ How?__________________________

Does he/she react when he/she does not get his/her own way? How is it handled?
_____________________________________________________________________

____________________________________________________________________________

Is the entire family together for any time during the day?_______________________________

Eating Habits:
At what time does the child eat breakfast?________ Lunch?_________ Dinner?_________
Between meal snack?___________ Does the child feed himself/herself?_________________
What is the child’s general attitude towards eating?
____________________________________
If the child refuses to eat, how is this handled and by whom?____________________________
____________________________________________________________________________
Food
Favorites:_________________________________________________________________
Food
Dislikes:__________________________________________________________________
Food
Allergies/Intolerances:__________________________________________________________

Sleep Habits:
Does the child have his/her own room?_____ Shares room with other children?_____ or
parents?_______
At night sleeps form___________ to _________ Average hours of naps__________________
Attitude towards going to bed_____________________________________________________
If there is difficulty, how is this handled?
_____________________________________________
Habits associated with going to bed________________________________________________
Is bedwetting an issue?_______________ at nap time?_____________ at night?________

Toilet Habits:
Time at which child is taken to the bathroom?________________________________________
Can the child take himself/herself?____________ Time of bowel movement?__________
Regular?__________ Constipated?______ Does the child tell you when he/she needs to go
and does he/she go willingly?_____________________________________________________
Can he/she manage his/her clothes at the toilet?________ What words does he/she use for:
Urinating:___________________________ BM _____________________________________

Speech and Physical Growth:

The child talks: ____ well _____ Fairly well ______ Not at all
Does anyone read to the child?_____ How Regularly?___________________
At what age did the child creep?______ Crawl?________ Walk?___________
Which of the following words would you use to describe the child (check all that apply):
___active ____quiet ____thin ____average weight ___heavy ____tall
____average height ____short ____friendly ____unfriendly ___agressive
Is there any other information you think we should have about the child?__________________
____________________________________________________________________________

Ongoing Medical Care:

Does the child have any medical diagnosis that requires ongoing care?___________________
If yes, explain what type of care is administered at home and by whom?__________________
____________________________________________________________________________
Are you requesting that this care be provided at the facility?_____ Yes ______ No if yes,
describe the care
required:________________________________________________________
____________________________________________________________________________
(we may request a doctor’s statement for any specific requests for care at the facility).

Are there any other comments or information you would like to let me know about?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Any specific concerns?

___________________________________________________________
____________________________________________________________________________

Parent Declarations:
I/we received a summary of the licensing requirements.
I/we do hereby authorize emergency medical care for my child ( a limited power of attorney may
be required for military dependents).
I/we received a copy of the child care facility’s policy statement or handbook, and payment
contract, and I/we have signed their copy, verifying by receipt my understanding and agreement
of their content.
I/we authorize The Academy of Development to transport my child as specified in the
transportation plan.
I/we toured the facility prior to enrolling my child(ren)
on______________________________________

_________________________________________________ _____________________
Signature of Parent/Guardian Date

_________________________________________________ _____________________
Signature of Parent/Guardian Date

Date of Child’s Withdrawal:__________Reason for withdrawal:__________________________

This form/information shall be maintained for one year after the date of disenrollment.

Information on this form shall be updated annually or as needed to ensure the protection of the
child.

Date of last update with parents initials:.

1.
2.
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