Crossroads Daycare Family Questionnaire

Child and Family Questionnaire

Child's Information

(Please complete one form per child enrolled)
Child's Name Child's Name * First Last
Nickname (Preferred Name)
Birthdate Birthdate * / MM / DD YYYY
Start Date at Crossroads Daycare Start Date at Crossroads Daycare * / MM / DD YYYY
Days of the Week Attending

Days of the Week Attending Monday Thursday Tuesday Friday Wednesday
Drop Off Time (approximate): Drop Off Time (approximate): * : HH MM AM/PM
Pick Up Time (approximate): Pick Up Time (approximate): * : HH MM AM/PM
Home/Best Cell Number Home/Best Cell Number * - ### - ### ####
Child's Primary Address Child's Primary Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Gender *
Sponsor/Parent/Guardian Information

**Please note if custody is shared by both parents/guardians, Crossroads Daycare will abide by documentation provided on this enrollment application.
Mother/Guardian Name Mother/Guardian Name * First Last
Please select all that apply:

Please select all that apply: Mother/This Guardian has primary custody? Court Documentation Will be Provided
Mobile Phone Number Mobile Phone Number * - ### - ### ####
Alternate Phone Number Alternate Phone Number * - ### - ### ####
May we text you? *

May we text you? Yes No
Best Email *
Home Address (only if different than childs primary address) Home Address (only if different than childs primary address)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Relation to Child: *
Employer (type none if not applicable) *
Work Phone (type all zeroes if none) Work Phone (type all zeroes if none) * - ### - ### ####
Work Address (type not applicable if it doesn't apply) Work Address (type not applicable if it doesn't apply) *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Best Way to Contact during Work Hours? *
Father/Second Guardian (if applicable)
Please select all that apply:

Please select all that apply: Father/This Guardian has primary custody? Court Documentation Will be Provided
Mobile Phone Mobile Phone - ### - ### ####
Alternate Phone Alternate Phone - ### - ### ####
May we text you?

May we text you? Yes No
Best Email
Home Address (if not the same as child's primary, first parent, or sponsor) Home Address (if not the same as child's primary, first parent, or sponsor)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Relation to Child:
Employer (type none if not applicable)
Work Phone (type all zeroes if none) Work Phone (type all zeroes if none) - ### - ### ####
Work Address (type not applicable if it doesn't apply) Work Address (type not applicable if it doesn't apply)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Best Way to Contact during Work Hours?
Emergency Information
In case of an illness or emergency who is to be contacted first?

In case of an illness or emergency who is to be contacted first? Mother/First Guardian Father/Second Guardian
Please give names of persons to call, other than sponsors or parents listed above in case of an emergency should arise and the sponsors cannot be reached.
Emergency Contact #1 *
Relationship to Child: *
Home Phone Home Phone * - ### - ### ####
Work Phone Work Phone * - ### - ### ####
Mobile Phone Mobile Phone * - ### - ### ####
Emergency Contact #2 *
Relationship to Child *
Home Phone Home Phone * - ### - ### ####
Work Phone Work Phone * - ### - ### ####
Pick Up List

I hereby authorize the release of my child to leave the school ONLY with the following people (do not list the sponsor/parents/guardians listed above as they are already included in this list).
Name (first) Name (first) First Last
Mobile Phone (first) Mobile Phone (first) - ### - ### ####
Name (second) Name (second) First Last
Mobile Phone (second) Mobile Phone (second) - ### - ### ####
Name (third) Name (third) First Last
Mobile Phone (third) Mobile Phone (third) - ### - ### ####
Please Initial if you agree to the following. Type NO to indicate you do not agree:
I agree that my child may be photographed at the child care center. We may share this photos with other families via email, newsletters, and/or social media pages? *
Maximum of 3 characters allowed. Currently Entered: 0 characters.
I agree that my child may take approved field trips sponsored by the center.
Maximum of 3 characters allowed. Currently Entered: 0 characters.
About your child:
How would you describe your child's personality:
Does your child have any known health concerns and/or allergies? Is so, please describe in detail:
Are there any languages other than English spoken at home?
Please list all adults and their relation to your child who live in the home:
Please list all children with their age, grade and their relation to your child that live in the home:
Is your child potty trained? *

Is your child potty trained? Yes No
Does your child use? *
If currently potty training, what specific actions can we take in the classroom to support you and your child in this process? While we cannot guarantee to do everything you suggest, the more details you give the more equipped we are to help.
Any allergies/aversions to certain brands of diapers/wipes/ointments?
What are your child's eating habits at home? Favorite foods? Food dislikes?
Please list any foods that your child should not eat due to allergies, tastes, reactions and/or religious beliefs include the food name and state the reason it is prohibited or write none (if it is not applicable)? *
My child will eat breakfast/morning snack at the center? If no, you must ensure your child eats BEFORE coming into the center.

My child will eat breakfast/morning snack at the center? If no, you must ensure your child eats BEFORE coming into the center. Yes No
Does your child take naps? *

Does your child take naps? Yes No
If yes, at what time?
Please explain your child's sleeping habits. Does he/she have a special "lovey" that helps at naptime or any other things that help your child fall asleep and sleep peacefully?
Pull ups at nap time? *

Pull ups at nap time? Yes No
Any limits on nap length (explain)?
Your child talks:

Your child talks: Well Fairly Well Not Very Well Not at All
What age did your child sit up?
What age did your child crawl?
What age did your child walk?
Do you have any concerns regarding your child's developmental progress? If so, please describe in detail (speech delays, motor delays, behavior concerns, etc.?) *
Please list any medications your child takes. Note: Any medications brought by parents must be in their original container, labeled with the child's name, labeled with the date (prescriptions), include directions for administering, and have a doctor's consent if prescription medication. *
Please list any special needs your child has or write none (if it is not applicable)? You may list anything you feel is important for us to understand about your family, work schedule or lifestyle that you feel we should know to provide the highest level of care for your child. *
Upload your completed Emergency Information & Immunization Record Card (should be completed, printed, signed, and scanned. The document size cannot be larger than 8 Mb)

Attach Files
One of these MUST acompany the EIIR card above: official copy of immunization record, Religious Beliefs Exemption, Medical Exemption, or a Signed Lab Proof of Immunity Form (file size less than 8 Mb)

Attach Files
Agreement:

Please check off each item after reading and sign:
I... *

I... authorize emergency medical care for my child have read and agree to the content in the Parent Handbook have read and understand our web camera policies agree to pay tuition on time and understand late payments are subject to a late fee will pick up my child no later than 6:00 p.m. or will pay a late fee will give 2 weeks notice upon unenrolling my child or will pay 2 weeks tuition have received summary of the licensing requirements (in parent handbook) will keep my child's immunizations up to date and provide a 121 Immunization Form
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Crossroads Daycare Family Questionnaire

Crossroads Daycare Family Questionnaire

Child's Information

Sponsor/Parent/Guardian Information

Emergency Information

Pick Up List

Please Initial if you agree to the following. Type NO to indicate you do not agree:

About your child:

Agreement: