Shaw Crest Academy Intake Forms
1. Child Personal Data
Childs Full Name
Nickname if any
Date of Birth
/
Month
/
Day
Year
Date
Gender
Home Address
ParentGuardian Names
Relationship to Child
Email Address
example@example.com
Primary Phone Number
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Authorized Pick-Up Persons (Name, Phone, Relationship)
Format: (000) 000-0000.
Emergency Contacts (Name, Phone, Relationship):
2. Medical & Health Information Form
Pediatrician Name
Pediatrician Phone
Format: (000) 000-0000.
Preferred Hospital
Insurance Provider Policy
Allergies: food, medication, environmental
Medications currently taken:
Chronic conditions: (ex. asthma, diabetes)
Vaccination Record attached copy or list
Permission to administer over-the-counter medications Yes or No
Authorization for emergency medical treatment signature required
3. Daily Schedule & Routine Information Form
Typical wakeup time
Nap schedule
Feeding schedule include amounts and times for infants
Food restrictions preferences
Favorite activities or toys
Comfort items: blanket, pacifier, etc...
Behavior/soothing techniques
Potty training status/bathroom routine
4. Permissions & Authorizations Form
Permission for outdoor play:
Yes
No
Permission for water activities (sprinklers, splash pad):
Yes
No
Permission for photographs/videos (for internal use, projects, newsletters):
Yes
No
Permission to go on short neighborhood walks:
Yes
No
Permission to apply sunscreen/diaper cream:
Yes
No
Permission to attend field trips:
Yes
No
Permission to use the internet/artificial intelligence (AI):
Yes
No
ParentGuardian Signature
Date
/
Month
/
Day
Year
Date
5. Child Development & Background Form
Languages spoken at home
Siblings ages and names
Childs strengths
Areas needing support
Previous daycare or group care experience
Separation anxiety concerns
Cultural or religious practices to respect
Parent expectations or goals for child at daycare
6. Agreement & Policy Acknowledgment Form
I have received and reviewed the Parent Handbook
Yes
No
I agree to follow the attendance, health, and payment policies
Yes
No
I understand the illness and late pick-up policies
Yes
No
Signature
Date
/
Month
/
Day
Year
Date
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