BEST OF CARE

This confidential form is to help your child care provider support the growth and development of your child while creating a safe, stable and healthy environment for all children. By providing complete information about your child, you will be assisting us in creating a positive experience for your child while in child care. Instructions: This form is to be completed by a parent/guardian and must be on file at the child care facility on or before a child's first day of attendance. If additional space is needed, attach a separate sheet of paper.

CCA-1200AFORFF (4-16) - Page 48

Arizona Department of Economic Security

CHILD'S NAME

DATE OF BIRTH

Date

What is your preferred method of communication?

PARENT/GUARDIAN COMPLETING THIS FORM

PROVIDER/CENTER NAME

Has your child attended child care in the past?

If yes, what type of setting(s) was your child in? (Family child care, group care, etc.)

What did you like most about your child's previous child care setting?

What did you like least?

Other comments

What is important to you about your child's care?

Who is important to your child?

Does your child prefer to play alone or with other children?

Does your child have a favorite toy or comfort object? If yes, what?

What is your child's current sleep schedule?

Does your child fall asleep easily?

What is his/her mood upon waking?

What does your child like?

What does your child dislike?

See reverse for EOE/ADA/LEP/GINA disclosures

CCA-1200A FORFF (4-16) - Page 2

CCA-1200AFORFF (4-16) - Page 49

Arizona Department of Economic Security

Special things you say or do to comfort your child are?

How does your child react when something unexpected happens?

How does your child react when something he/she doesn't like happens?

How do you when your child is happy?

Does your child have any health issues?

If yes, please explain

Does your child have any other special needs?

If yes, please explain

Is there anything else you would like to share about your child that you feel would help us create a positive environment and relationship for your child?

Parent/Guardian declined to complete

Parent/Guardian Signature

Clear

Date

Equal Opportunity Employer/Program Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allowa person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact 602-542-4248; TTY/TDD Services: 7-1-1.Free language assistance for DES services is available upon request.Disponible en español en línea o en la oficina local. CCA-1200AFORFF (4-16) - Page 50Arizona Department of Economic Security

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

BEST OF CARE