Child Enrollment

1. Child’s Profile

Full Legal Name:

Preferred Name/Nickname:

Child's Date of Birth

Child's Gender identity

Child's Pronouns (optional):

Languages Spoken by Child:

Child’s Primary Residence Address:

Postal Code:

2. Developmental & Health Background

Please provide details of any diagnosed medical conditions or developmental concerns you child has.

Has your child been evaluated by any specialists (e.g., speech therapist, occupational therapist)?

Please list any allergies or food restrictions your child may have.

Is your child on any medication? If yes please provide details.

Does you child follow a specific diet? If yes please provide details.

Does your child require assistance with toileting or personal hygiene?

Yes

No

Are there any sensory sensitivities or triggers we should be aware of?

Yes

No

Please describe your child’s communication style (verbal, non-verbal, use of assistive devices):

Does your child require mobility support or adaptive equipment?

Yes

No

3. Family Contacts

Primary Parent/Guardian Name:

Primary Parent/Guardian's Relationship to Child:

Primary Parent/Guardian's Phone Number(s):

Primary Parent/Guardian Email

Secondary Parent/Guardian Name (if applicable):

Secondary Parent/Guardian's Relationship to Child:

Secondary Parent/Guardian's Phone Number(s):

Names, ages, and relationships of siblings or other children living in the home:

Names, ages, and relationships of other household members over 13 years:

Is anyone in the home a smoker (tobacco or cannabis)?

Yes

No

Does anyone in the home consume alcohol?

Yes

No

Does anyone living in the home have a criminal record?

Yes

No

4. Custody and Legal Considerations

Are there any custody arrangements or legal restrictions involving your child?

Yes

No

If yes, please provide relevant documentation and details:

Are there any individuals prohibited from picking up your child?

Yes

No

Are you currently receiving or applying for government childcare subsidies?

Yes, Receiving

Yes, applied and waiting

Would like information

No

5. Emergency Contacts

Please provide at least two contacts other than parents/guardians who can be reached in an emergency:

Contact 1: *

Emergency Contact 1: Full Name:

Emergency Contact 1: Relationship to Child:

Emergency Contact 1: Phone Number

Emergency Contact 1: Alternate Number:

Contact 2: *

Emergency Contact 2: Full Name:

Emergency Contact 2: Relationship to Child:

Emergency Contact 2: Phone Number:

Emergency Contact 2: Alternate Number:

Childcare Request.

Preffered Start Date:

Does your child require transportation from/to school? If yes please specify:

Please list any information regarding your child that their caretaker should know.

I confirm that all information provided is accurate to the best of my knowledge. I authorize 1 for 6 Kiddos Home Childcare Agency to use this information to provide appropriate care and to contact emergency contacts if necessary.

We Are Exited to Meet You!

Child Enrollment

1 For 6 Kiddos Corp.