Parent's Day Out Child Application

A Ministry of Calvary Knoxville

Your name *

Last name

Email address *

Child Information Form

CK PARENTS DAY OUT

Household members

+ Add adult+ Add child

Name of Child:

Name Child Goes By (If Different From Above):

Child's Birthday *

Place of Birth:

Name(s) and age(s) of siblings:

Child lives with... *

Parents

Mother

Name of Mother: *

Address

HomeWorkOther

Country

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Employer:

Work Hours

Phone number *

Phone type

MobileHomeWorkOther

Email Address: *

Father

Name of Father *

Address

HomeWorkOther

Country

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Employer:

Work Hours:

Phone number *

Phone type

MobileHomeWorkOther

Email Address: *

Home Church:

SPECIAL CONCERNS:

Food Allergies? *

Environmental Allergies? *

Craft Materials Child Might be Allergic to? *

Physical Limitations? *

Motor Skill Difficulties? *

Hearing Concerns? *

Speech Concerns? *

Vision Concerns? *

ADD | ADHD? *

Please list any medications regularly taken by your child:

SOCIAL HISTORY:

How would you describe your child?

Active

Quite

Friendly

Shy

Other

Has your child experienced any problems in the following areas? If so, please explain.

Eating

Sleeping

Elimination

Discipline

Speech/Hearing/Vision

Biting Others

Aggressiveness

Seperation Anxiety

EVENTS

Has your child had any of the following experiences in the past year?

Birth of another child in the family

Yes

No

Moving Residence

Yes

No

Changing Schools

Yes

No

Serious illness of a child or family member?

Yes

No

Death in Family?

Yes

No

Divorce of parents?

Yes

No

Other?

Special Concerns?

If parents are divorced, who has custody?

List anyone who does NOT have permission to pick up your child. If parent, please provide court/legal documents.

GENERAL CHARACTERISTICS

Height *

Weight *

Hair Color *

Eye Color *

Gender *

HEALTH HISTORY

Medical Diagnoses:

Any prescription meds the child takes regularly?

CHECK ANY THAT APPLY TO YOUR CHILD

Hospitalized

Asthma or wheezing

More than two ear infections in one year

Heart Murmur

Burning during urination

Kidney or bladder infections

Tested positive for tuberculosis

Heart Monitor

Had worms

Contact with TB

Seizures or shaking

Tonsillitis

Tics

Other

IS YOUR CHILD (Check all that Apply)

Taking Medication

Able to play as hard as others

Usually happy

Having vision problems

Hemophiliac (Free Bleeder)

DOES YOUR CHILD (Check all that Apply)

Have ear tubes

Get along with other children

Scratch bottom or have sensitive bottom

Special Medical Concerns Not Listed Above:

Is your child potty-trained (able to use the bathroom unassisted)? *

Yes

No

Background Information

Did you child attend any other early childhood programs prior to now? *

Yes

No

If yes, where?

What are some ways your child plays at home?

Does your child usually get his/her own way with other children? *

Yes

No

If not, what is their reaction?

What are your child's favorite activities?

What are your child's least favorite activities?

What are your child's favorite foods?

What are your child's least favorite foods?

How can we best help your child in this program?

Submit

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.