Southeast Baptist Church - Daycare Application

Child's Information

Child's Full Name

What does the child like to be called

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Child's Birthdate

Gender

Date you would like for your child to start

Mother's Information

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Employeer

Work Phone Number

Work days and hours

Father's Information

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Employeer

Work Phone Number

Work days and hours

Transportation Plan

To ensure the safety of your child, please list names and phone numbers of other adults to whom your child may be released or who are authorized to provide transportation for your child. If I, or anyone who may be authorized to pick up my child/children appear to be under the influence of drugs, alcohol, or are showing any other type of risky behavior, please contact any of the following listed below, and I hereby give my permission for my child/ children to leave with any of these listed.

First Name

Last Name

Phone Number

Email

First Name

Last Name

Phone Number

Email

First Name

Last Name

Phone Number

Email

Other Children in the Family

First Name

Last Name

Birthdate

School

First Name

Last Name

Birthdate

School

First Name

Last Name

Birthdate

School

Emergency Contact Information

Name of person, other than mother or father listed above, authorized to act for parents in an emergency.

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Employeer

Work Phone Number

Work days and hours

Experience with Others

What are some ways in which the child plays at home?

How well does the child play with other children?

How will your child react if they do not get their own way?

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

Eating Habits

At what time does your child eat Breakfast?

At what time does your child eat Lunch?

At what time does your child eat Dinner?

Does your child usually eat snacks between meals?

Yes

No

Does your child feed him/herself?

Yes

No

What is your child's general attitude toward eating?

If your child refuses to eat, how is it handled and by whom?

What are you child's favorite foods?

What foods does your child dislike?

Sleep Habits

Pick one

Sleeps with parents

Sleeps in a room with a sibling

Sleeps alone

How many hours does your child normally sleep at night?

How many hours does your child normally nap in the afternoon?

What is your child's attitude toward going to bed?

If there is any difficulty, how is it handled?

Are there any habits your child does before going to bed?

Does your child wet the bed?

At night

At nap

If so, how is it handled?

Toilet Habits

Is your child completely potty trained?

Yes

No

Does your child tell you when they need to go potty?

Yes

No

Can your child manager his/her clothing at the toilet?

Yes

No

What word does your child use for urination?

What word does your child use for a bowel movement?

Permission to Photograph/Video

From time to time, we take pictures/videos during daily activities. We would like your permission to use this media on our website, in our newsletters, and/or social media. We will never reference your child by name or provide any specific information regarding your child

Do we have permission to use photos/videos of your child

YES

NO

Signature

By signing below, I acknowledge that the information in the application is, to the best of my knowledge, accurate and free from deception.

Signature

Today's date

Daycare Application

Child's Information

Mother's Information

Father's Information

Transportation Plan

Other Children in the Family

Emergency Contact Information

Medical Information

Experience with Others

Eating Habits

Sleep Habits

Toilet Habits

Speech & Physical Growth

Permission to Photograph/Video

Signature