All About Me!

Child’s Name ____________________________ Nickname ____________________________

I have _____ brothers & _____ sisters, their names and ages are: ________________________

_____________________________________________________________________________

How would you describe your child’s personality?

Has your child been in child care before? ( ) Yes ( ) No. If yes, please give last child care

provider, or daycare center’s information:

Name: ________________________________________ Phone _________________________

Dates Attended: from ________ to _________. Why was care terminated? ________________

_____________________________________________________________________________

May I contact them for a reference? ( ) Yes ( ) No

Does your child have a regular bedtime schedule? ( ) Yes ( ) No. What time does your child

usually go to bed at night? ___________. What time does your child usually wake up in the

morning? __________. Does your child have trouble sleeping? ( ) Yes ( ) No. Night Terrors?

( ) Yes ( ) No. Trouble going to sleep? ( ) Yes ( ) No. Other: ____________________________

_____________________________________________________________________________

If infant how does your child sleep? ( ) Stomach ( ) Side ( ) Back. What time(s) and for how

long does your child usually nap? ___________________________________. Are there any

special dolls, blankets, etc that your child needs to go to sleep? __________________________

What is your child’s disposition upon waking? ( ) Happy ( ) Grouchy ( ) Clingy ( ) Slow

( ) Other _____________________________________________________________________

Has or does your child have any known health problems? ( ) Yes ( ) No. If yes, please describe:

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