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Child Questionairre
This information will help me prepare for your tour as well as your child's first introduction into my child care home. It will help me understand what your expectations are as well as provide information that will help me best prepare for your child. It will help ensure we are on the same page as far as the care of your child goes and help me bring up any questions I may have during the interview process. Please complete all applicable questions.
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Child's Name
Your answer
Child's Date of Birth
MM
/
DD
/
YYYY
What are your desired days and hours of care?
Your answer
Do you plan to use DHS subsidy for paying for child care?
Yes
No
Maybe
Clear selection
What is your child's vaccination status?
Current (including flu shot)
Current (except flu shot)
Delayed (for medical reason)
Delayed (for personal reason)
Not vaccinated
Does anyone in your home smoke?
Yes
No
Clear selection
Please describe your child's sleeping environment at home. (Select all that apply)
In a crib
In a bed
Swaddled
Unswaddled
Room Shares
Bed Shares
White Noise
Quiet
Dark
Dimly lit
In room alone
In a room with others
pacifier
blanket
pillow
stuffed animal
Other:
If your child is under 12 months, have they been introduced to a bottle, and do they drink easily from it?
Yes
No
Clear selection
Does Your child have any special dietary needs?
Your answer
Has your child been in daycare before? If yes, where?
Your answer
Was your child born pre-term? If so, how early?
Your answer
What is your child's daily routine? (Please include eating and sleep times)
Your answer
Are your childs ears pierced?
Yes
No
Clear selection
What are your expectations of me? (ie what do you expect your child's day to be like, or expect him/her to learn or do?)
Your answer
Do you have any indoor pets? If so, what kind?
Your answer
Do you have local back up care available in case of an emergency on my part?
Yes
No
Clear selection
Please explain how tantrums are handled in your home.
Your answer
What is your biggest fear about child care?
Your answer
What is your highest priority for a child care facility?
Your answer
What are your child's favorite foods?
Your answer
What are some of your child's favorite toys?
Your answer
What are your child's favorite activities? Both Indoors and out?
Your answer
How does your child like to be comforted?
Your answer
Please indicate which of the following you would allow for your child while in my family childcare home.
Have sunscreen applied that is supplied by the daycare
Have insect repellent applied that is supplied by the daycare
Engage in "risky" or "rough" play that may include running, jumping, skipping, hopping, or playing with rocks or sticks
To be photographed.
My child’s picture to be posted to FaceBook, Baby Connect, posted in the child care home, or used in marketing materials
Information on my child’s acute contagious illnesses including symptoms or diagnosis to be shared with the parents of other children in care (the name of the child will be redacted). This allows parents to be aware of what signs of illness to be alert for and allow them to take any precautions necessary.
Be only in a diaper for messy play/meals.
Play outside barefoot.
Have toe nails or fingernails trimmed.
Use Diapers and/or wipes supplied by the daycare
Brush their teeth independently (no toothpaste only toothbrush and water).
Please eleaborate on any special needs your child has.
Your answer
If there is anything else you would like me to know about your child/family or any concerns you have please share them here.
Your answer
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