* = Required Information
Department of Human Resources
Child Care Administration
All About
Child's First Name or Nickname
*
Child's Name
*
Birthdate
*
Parent or Guardian
Home Phone
Work Phone
Address
*
Zip Code
*
Provider Center
Phone
Address
Zip Code
The information contained is for CONFIDENTIAL USE ONLY
Things My child Does Will
WHAT MY CHILD LIKES AND DISLIKES
THINGS I AM WORKING ON WITH MY CHILD
MY CHILD ENJOYS THESE PHYSICAL ACTIVITIES
MY CHILD HAS A DIFFICULTY WITH THESE ACTIVITIES
MY CHILD WILL NEED THE FOLLOWING EQUIPMENT AND/OR ROUTINES
THINGS MY CHILD MIGHT NEED HELP WITH
WHAT SPECIAL ADAPTATIONS WILL THE PROGRAM MAKE AT THIS TIME?
(for the use of the Child Care Facility when needed)
This information is intended for use by the child care provider, developed in cooperation with the parents.
This is not intended to be a legally binding contract.
Name:
Parent or Guardian
Date
Provider
Date
Updates
Provider
Date
Provider
Date
Provider
Provider