Early Childhood Education Forms
General Information, Emergency Contacts, Developmental History and Background, Diaper/Topical/Sunscreen Application, Terms and Conditions
Child's Information
Child's Name
*
First Name
Last Name
Photo Identification: Please upload a current (color) photo of your child
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This photo will be used for identification purposes only and will be kept in your child's administrative file. Your child should be the only one to appear in the photo.
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Date of Birth
*
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Month
-
Day
Year
Date
Age
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Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Child Lives With:
*
Both Parents
Mother
Father
Other
Parent/Guardian (1) Info
Parent/Guardian (1) Name
*
First Name
Last Name
Parent/Guardian (1) Occupation
Parent/Guardian (1) Address (if different than child)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian (1) Home Phone
*
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Area Code
Phone Number
Parent/Guardian (1) Home Phone Priority
Call Home Phone First
Call Home Phone Second
Call Home Phone Third
Parent/Guardian (1) Business Phone
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Area Code
Phone Number
Parent/Guardian (1) Business Phone
Call Business Phone First
Call Business Phone Second
Call Business Phone Third
Parent/Guardian (1) Cell Phone
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Area Code
Phone Number
Parent/Guardian (1) Cell Phone Priority
Call Cell Phone First
Call Cell Phone Second
Call Cell Phone Third
Parent/Guardian (1) Email
*
example@example.com
Parent/Guardian (1) Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian (1) Business Name
Parent/Guardian (2) Info
Parent/Guardian (2) Name
First Name
Last Name
Parent/Guardian (2) Occupation
Parent/Guardian (2) Address (if different than above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian (2) Home Phone
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Area Code
Phone Number
Parent/Guardian (2) Home Phone Priority
Call Home Phone First
Call Home Phone Second
Call Home Phone Third
Parent/Guardian (2) Business Phone
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Area Code
Phone Number
Parent/Guardian (2) Business Phone
Call Business Phone First
Call Business Phone Second
Call Business Phone Third
Parent/Guardian (2) Cell Phone
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Area Code
Phone Number
Parent/Guardian (2) Cell Phone Priority
Call Cell Phone First
Call Cell Phone Second
Call Cell Phone Third
Parent/Guardian (2) Email
example@example.com
Parent/Guardian (2) Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian (2) Business Name
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Emergency Contact
Please list at least one (other than parent/guardian)
Emergency Contact (1) Name
*
First Name
Last Name
Relationship to Child
*
Number to Call First:
Home Phone
Business Phone
Cell Phone
Home Phone
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Area Code
Phone Number
Business Phone
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Area Code
Phone Number
Cell Phone
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Area Code
Phone Number
Emergency Contact (2) Name
First Name
Last Name
Relationship to Child
Number to Call First:
Home Phone
Business Phone
Cell Phone
Home Phone
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Area Code
Phone Number
Business Phone
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Area Code
Phone Number
Cell Phone
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Area Code
Phone Number
Authorized Pick-Up
Person(s) to whom child may be released other than parent/guardian
Name
First Name
Last Name
Relationship to Child
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number to Call First:
Home Phone
Business Phone
Cell Phone
Home Phone
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Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Business Phone
-
Area Code
Phone Number
Name
First Name
Last Name
Relationship to Child
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number to Call First:
Home Phone
Business Phone
Cell Phone
Home Phone
-
Area Code
Phone Number
Cell Phone
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Area Code
Phone Number
Business Phone
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Area Code
Phone Number
Parental Consent
Parent/Guardian signature is required for each item below to indicate parental consent. Please note, if the permission to obtain medical care and permission to administer minor first aid procedures fields are left blank we will be unable to treat your child should either of these situations occur.
Obtain emergency medical care (Initial below)
Administration of minor first aid procedures (Initial below)
Walking and trips (Initial below)
Transportation by the facility (Initial below)
Swimming (Initial below)
Wading (Initial below)
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Child's Physician/Medical Care Provider
Doctor's Name
Office Phone
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Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Local Hospital Preference
Health Insurance/Information
Health Insurance Company
Health Insurance Group #
Health Insurance ID#
Does your child have any special physical, educational, emotional, or medical needs or disabilities? If so, please describe in detail so that our staff can provide the best possible care. (All information will remain confidential)
List any allergies and/or reactions (including medication reaction)
Does your child take any regular medications?
Include any medical or dietary information necessary in an emergency situation
List any permanent birthmarks or other physical markings (i.e. hemangioma)
Does your child experience any of the following:
Frequent Headaches
Frequent Stomach Aches
None of These
Additional information on special needs of child
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Developmental History and Background Information
Please only fill this section out if you are new to the JCC. Regulation for licensed childcare facilities require this information to be on file to address the needs of children while in care.
Age Began Sitting
Age Began Crawling
Age Began Talking
First Words
First Sentences
Did your child babble or make play noises during infancy?
Yes
No
Primary Language Spoken at Home
Other Language(s) Spoken at Home
Has your child demonstrated any difficulties or do you have any concerns about your child’s development in any of these areas (Choose all that apply)
Speech or Language
Motor Skills
Social Skills
Sensory
Cognitive (Intellectual)
Behavioral
If answered yes to any of the above, please describe.
Does your child use a pacifier or suck their thumb? If so, when?
Does your child have fussy time? If so, when?
How do you handle this?
Health
Any known complications at birth?
Any serious illnesses and/or hospitalizations?
Eating Habits
Was/is your child bottle fed? If so, for how long and with what formula?
Was/is your child breast fed? If so, for how long?
Please list any special characteristics, difficulties, or eating restrictions.
If your child is on any special formula, please give the name and describe its preparation in detail.
Is your child fed:
Held in Lap
In a High Chair
Both
Does your child eat with:
a Spoon
a Fork
Their Hands
Toilet Habits
Is your child toilet trained?
Yes
No
In Progress
If no, has toilet training been attempted?
Yes
No
Concerns?
Do they need to be reminded? If yes, how often?
What word does your child/family use for urination?
What word does your child/family use for bowel movement?
What type of diapers are used?
Disposable
Cloth
Is there a frequent occurrence of diaper rash?
Yes
No
Are bowel movements regular? How many per day?
Is there a problem with:
Diarrhea
Constipation
Please describe any particular procedure to be used for your child at the center.
What is used at home:
Potty Chair
Special Child Seat
Regular Seat
How does your child indicate bathroom needs (Include special words)
Is your child reluctant to use the bathroom?
Yes
No
Does your child have accidents?
Yes
No
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Application of Diaper/Topical Cream/Sunscreen
Please clearly label the item(s) listed below with your child's full name and submit to the ECE Office.
Name of diaper, topical cream, and/or sunscreen:
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Please submit your child's health and TB forms.
One submission must be made per child. If you have hard copy forms, they may be turned into Lisa Yoskowitz, ECE Director, in the ECE Office.
Download blank forms:
Child Health Form |
Download
Allentown Tuberculosis Form |
Download
Upload Your Health Form
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Upload Your TB Form
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ECE Terms and Conditions
Today's Date
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Month
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Day
Year
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Parent/Guardian Signature
*
By signing, I acknowledge that I have read and completed this form accurately and in its entirety.
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