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ELC Developmental History and Background Information

Please note: All field are required. Please type N/A if info is not applicable.

* Child's Name

* Child's Date of Birth

Developmental History

Please provide information for Infants & Toddlers (marked*) as appropriate to the age of your child.

* Age began sitting?

* Age began walking?

* Age began crawling?

* Age began talking?

* Does your child have any speech difficulties?

* Does your child have any special words to describe his/her needs?

* What language is spoken at home?

* Is there any history of colic?*

* Does your child use a pacifier or suck thumb? If so, when?*

* Does your child have a fussy time? If so, when?*

* How do you handle this time?*

Health

* Any known complications at birth?

* Serious illnesses and/or hospitalizations?

* Special physical conditions, disabilities?

* Allergies (i.e., astham, hay fever, insect bites, medicine, food reactions)?

* Regular Medications?

Any medications to be administered at school requires an additional form signed by licensed physician.

Eating Habits

* Special characteristics or difficulties?

* Favorite Foods?

* Foods Refused

* Does your child eat with a spoon?*

* Does your child eat with a fork?*

* Does your child eat with a hands?*

Toilet Habits

* Are disposable or cloth diapers used?*

* Is there a frequent occurrence of diaper rash?*

* Do you use oil, powder, lotion and/or other?*

* Are bowel movements regular?*

* How many per day?*

* Is there a problem with diarrhea?*

* Is there a problem with constipation?*

* Has toilet training been attempted?*

* Please describe any particular procedure used for diapering or toileting to be used at Temple Beth Avodah.*

* Is a potty chair used at home?*

* Is a special child seat used at home?*

* Is a regular seat used at home?*

* How does your child indicate bathroom needs? Please include specific words.*

* Is your child ever reluctant to use the bathroom?

* Does your child have accidents?

Sleeping Habits

Please note: The American Academy of Pediatrics has determined that placing a baby on his/her back to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden and unexplained death of a baby under one year of age. If your child does not usually sleep on his/her back, please contact your pediatrician immediately to discuss the best sleeping position for your baby. Please also take the time to discuss your child's sleeping position with your caregiver.

* When does your child go to bed at night?

* When does your child get up in the morning?

* Describe any special characteristics or needs (stuffed animal, story, mood on waking etc.)

Social Relationships

* How would you describe your child?

* Previous experience with other children/day care.

* Reaction to strangers.

* Is your child able to play alone?

* Favorite toy and activity?

* Fears (the dark, animals, etc.).

* What is the method of behavior management/discipline used at home?

* What would you like your child to gain from this childcare experience?

Daily Schedule

* Please describe your child's schedule on a typical day. For infants, please include awakening, eating, time out of crib/bed, napping, toilet habits, fussy time, night bedtime, etc.

* Is there anything else we should know about your child?

Signature & Date

* By typing my name below and clicking "Submit" I hereby constitute that this is my electronic signature for legal purposes.

* Date