Confidential Child Information Form

Parent/Guardian #1

Parent/Guardian #2

Parent’s Marital Status

Does the child reside with someone other than parent or guardian?

Yes

Persons other than parents/guardians to contact in case of emergency:

Name	Relationship	Phone Number

Individuals authorized to pick up child:

Name
Name
Name
Name

Medical Background History

Does your child have any history of medical problems, serious illness or accidents?

Yes

Is your child currently under the care of a physician for the above named condition or any other reason?

Yes

Does your child take any medications or vitamins regularly?

Does your child have any food or non-food allergies?

Yes

Does your child have any special medical needs?

Yes

Developmental And Social History

Does your child have any history of developmental disabilities, such as delayed speech, motor development, walking, etc?

Yes

Does your child speak and understand English?

Yes

Please describe any help your child needs for:

Does your child play with other children and interact with adults on a regular basis?

Yes

Please tell us what makes your child special. Is there something unique about them, like a talent or a trait that makes them stand out? Also, are there any things your child is afraid of or doesn’t like? We’d also like to know what your child’s favorite things are—things they love to do, eat, or play with. What helps your child feel calm and safe? How does your child show their feelings, like when they are happy, sad, or upset? Finally, are there any routines or habits that make your child feel more settled or secure?