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Rising Stars Student Enrollment Application
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* Indicates required question
Email
*
Your email
Phone Number:
Your answer
Child's Full Name
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Anticipated Date for Care to Begin:
*
MM
/
DD
/
YYYY
Parent or Guardian Full Name(s):
*
Your answer
With whom does the child reside (parent(s), siblings, extended family, pets)?
*
Your answer
Explain your custody situation.
*
Your answer
Language(s) spoken at home:
*
Your answer
Are there cultural or family customs, rituals, or traditions that will help us make your child’s experience more meaningful?
*
Your answer
Describe any special physical conditions, disabilities, or allergies?
*
Your answer
Has your child been diagnosed with a special need? If so, is your child receiving any special services?
*
Your answer
Regular medications?
*
Your answer
Describe any serious illnesses or hospitalizations:
*
Your answer
Any food allergies or eating preferences:
*
Your answer
Toilet and Diapering Habits
Is your child toilet trained?
*
Urination
Bowels
Not Trained
Required
Does your child use the toilet independently?
Yes
No
Clear selection
Comments:
Your answer
Is there a problem with:
Diarrhea
Constipation
What is used at home:
Potty Chair
Special Seat
Regular Seat
Does the child have accidents? If so, how frequently?
Your answer
Sleeping Routine
Pre-nap routines/rituals:
*
Your answer
How many naps per day (typical)
*
Your answer
Length of nap (typical):
*
Your answer
Sleep concerns:
*
Your answer
Separation and Comfort
Does your child have a security object? If so, name, specific object?
*
Your answer
Has your child been left in the care of someone other than yourself?
*
Yes
No
If so, with whom? And at what age?
Your answer
How does your child react when separating from you?
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Your answer
What are some ways to calm your child?
*
Your answer
How can we help you feel more comfortable and involved in the care of your child?
*
Your answer
Favorite toys and activities?
*
Your answer
Social Relationships
Would you characterize your child as often:
*
Friendly
Aggressive
Shy
Withdrawn
Required
Has your child had any experience playing with other children?
*
Yes
No
Are you currently approved for the Best Beginnings Childcare Scholarship?
*
Yes
No
Final Thoughts:
Referral Source:
*
Your answer
What do you as a family hope to get out of this childcare experience?
*
Your answer
We will update the personal care plan every 3 - 4months, or sooner if requested by a parent/guardian or as needed by the staff.
Send me a copy of my responses.
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