Childcare Information Intake Form
Update January 2023
Child's Full Name
Birthday
Current Age
Sex
Address
Parent 1 or Legal Guardian Name
Email
example@example.com
Parent 1 or Legal Guardian Cell Phone
-
Area Code
Phone Number
Email
example@example.com
List any allergies
Any recent serious illnesses or hospitalizations
Any Medical Accessories
Glasses
Contacts
Retainers
Braces
Please list any medical limitations your child may have
Does your Child have a diagnosed Special Need
Yes
No
When was your Child's last well Child Check?
Is your Child Immunized?
Yes
No
What school does your child currently attend?
Hawthorne
Anderson
Emerson Montessori
Greenwood Leadership
Drexel
Deborah Brown
Celia Clinton
McKinley
Mayo
Dual Language Academy
Homeschool
Not in school
Daycare
School Not Listed
Disclaimer: We do not offer afterschool pickup to school’s not listed. We DO NOT offer before school drop off.
Estimated Start Date
/
Month
/
Day
Year
Date
Please Choose Childcare Location Below
Shining Star Kids Academy (2131 East 31st Pl. North)
Ellemnopy Preschool & Playhouse (8730 East Skelly Dr.)
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