Ezion Fair Christian Community Academy (Center's Need To Know)

Ezion Fair Christian Community Academy

Center's Need To Know Information Checklist
1400 B Street * Wilmington, Delaware 19801 * Ph: 302.652.9114 * Fax: 302.652.7071 www.ezionfairacademy.org
(Please print clearly and respond to all fields)
CHILDS FULL NAME
CHILDS DAYCARE HOURS
DOES THE CHILD HAVE AN IEP If yes please provide
PARENTS EMPLOYMENT
WORK HOURS
EMERGENCY #1
Format: (000) 000-0000.
FULL NAME RELATIONSHIP
EMERGENCY #2
Format: (000) 000-0000.
FULL NAME RELATIONSHIP
DOCTORS NAME
DOCTORS ADDRESS
DOCTOR'S PHONE
Format: (000) 000-0000.
MY CHILD CAN BE RELEASED TO: (Name, Relation & Telephone Number)
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2
3
4
5
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PARENT SIGNATURE
DATE

MonthDayYear
Date
"A Little About My Child's Temperament"

Please provide a description of your child’s temperament.
Areas you would like to see your child working on
Your normal method of discipline
Child's Temperament

Easy GoingHard to PleaseDemandingAggressive
Childs favorite Activities
Food Restriction
Any special needs or concerns
General State of Health:

Please complete this section regarding your child’s health.
Are your child's immunizations up to date?
Are you concerned that your child may be prone to any type of allergies?

YesNo
If yes, please provide details below:
Does your child have any known allergies?

YesNo
If yes, please provide details below:
Does your child have any medical conditions in which we should known about?

YesNo
Has your child had any of the following common childhood illnesses? (Please check all that apply)

ConstipationFrequent ColdsSkin RashBronchititisHepatitisGerman MeaslesWormsConvulsionsFrequent Ear InfectionsSoilingChicken PoxImpetigoPolioTuberculosisDiarrheaFrequent Sore ThroatStomach UpsetDiabetesMeaslesScarlet FeverWhooping CoughRingwormAsthmaHeart DiseaseMumpsUrinary ProblemsFainting Spells
If yes, please provide details below:
Does your child have any speech, hearing, or visual problems?

YesNo
If yes, please provide details below:
Has your child been seen or tested for any of the above?
Has your child ever had surgeries or do they have any prosthetic limbs or etc?

YesNo
If yes, please describe below:
Would there be any restrictions to play or activities Ie child handicapped allergic to grass etc
General Emotional State of Health
Please describe how your child shows feelings in the following scenarios:
How does show his/her feelings when afraid?
How does show his/her feelings when happy?
How does show his/her feelings when angry?
How does show his/her feelings when intolerant?
What forms of discipline are most often used in the child's home?
How does your child feel about daycare and being separated from his or her mother/father?
Are there any recent traumatic situations the child has been exposed to such as: (death in the family, divorce, new siblings etc.? If yes, please describe:
How is your child easily settled when upset or afraid?
Are there any additional comments or information you would like us to know about your child?
Any specific concerns
Parent Signature
Date

MonthDayYear
Date
Parent Signature
Date

MonthDayYear
Date
Should be Empty:

Ezion Fair Christian Community Academy

"A Little About My Child's Temperament"

General State of Health:

General Emotional State of Health