CHILD DEVELOPMENT CENTER by 3vp6sY

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									          Application Fee $50.00 per child – Payable by check or money order – UT Child Care Program

CHILD DEVELOPMENT CENTER                                                                      Date received ______________________
711 Jefferson Avenue                                                                          Date desired _______________________
Memphis, Tennessee 38105                                                                      Enrollment ________________________
(901) 448-6586                                                                                Class _____________________________

APPLICATION

I. CHILD
Name: _______________________________________________________________________ Nickname_________________________ Sex_________
         Last                     First                 Middle

Address: _____________________________________________________________________________ Phone No. _____________________________
             House No.                      Street

        ___________________________________________________________
            City                           State                    Zip

Date of Birth ________________________________________________________ Place of Birth ____________________________________________
                Month             Day                    Year                                City          State     Country

Is child adopted? ________________________________ Guardian? ____________________________________________________________________
If living with guardian, please list the name, address, and phone number of Guardian.
___________________________________________________________________________________________________________________________

Name(s) of other day care program(s) attended: _____________________________________________________________________________________
___________________________________________________________________________________________________________________________

II. PARENTS
Father _____________________________________________________________________________________________________________________
         Last                                                First                             Middle
Address_____________________________________________________________________________ Home Phone ____________________________

Where Employed? ____________________________________________________________________ Occupation _____________________________
Work Hours _________________________________________________________________________ Work Phone _____________________________
Mother _____________________________________________________________________________________________________________________
         Last                                               First                        Middle
Address ____________________________________________________________________________ Home Phone _____________________________
Where Employed? ____________________________________________________________________ Occupation ______________________________
Work Hours _________________________________________________________________________ Work Phone _____________________________

III. EMERGENCY FRIEND AND DOCTOR
Name of person authorized to contact in case of emergency ___________________________________________________________________________
Address ________________________________________________________________________ Phone No. ___________________________________
Where Employed? _______________________________________________________________ Phone No. ___________________________________
Name of Family Doctor ________________________________________________________________________________________________________
Address _________________________________________________________________________ Phone No. __________________________________

IV BACKGROUND INFORMATION
Other Children in Family
               Name               Age             Sex                     School and Grade
______________________________ __________ _______________ _______________________________________________________________
______________________________ __________ ___ ____________ ______________________________________________________________
______________________________ __________ _______________ ______________________________________________________________
Other Adults living in home
          Name                                    Relationship to child
____________________________________________ ____________________________________________________________________________

V. HEALTH HISTORY
Has child been hospitalized? _______________________When? _________ Why? _______________________________________________________
Is child on medications? ___________________ If so, please describe __________________________________________________________________
___________________________________________________________________________________________________________________________
Is child allergic to certain substances (other than foods)? _____________________________________________________________________________
If so, please describe __________________________________________________________________________________________________________
Are there any health problems with which we should be aware? ________________________________________________________________________
          Application Fee $50.00 per child – Payable by check or money order – UT Child Care Program

VI. HEALTH HABITS
1. Eating: Appetite – Good _____ Fair _____ Poor _____ What is child’s general attitude toward eating? ______________________________________
If he/she refuses to eat, how is this handled? _______________________________________________________________________________________
Favorite foods _______________________________________________________________________________________________________________
Disliked foods _______________________________________________________________________________________________________________
Is child allergic to certain foods? ____________ If so, please list and describe ____________________________________________________________
Is child on a special diet? ______________________________________________________________________________________________________
If child is an infant, please provide information about formula, bottle schedule, and etc. _____________________________________________________
___________________________________________________________________________________________________________________________
2. Sleep Habits: At night sleeps from _______________ to _______________ Average hours ________________________________________________
Naps from _________________to ________________ Average hours __________________________________________________________________
Attitude toward going to bed ____________________________________________________________________________________________________
If there is difficulty, how is this handled? __________________________________________________________________________________________
Habits associated with going to bed? _____________________________________________________________________________________________
Does he/she wet the bed? _______________________________________________________ At nap time? ____________________________________
3. Toilet Habits: Time at which child is taken to the bathroom _________________________________________________________________________
Does he/she go themselves? ________________________ Time of bowel movement? _________________________ Regular? ____________________
Does he/she tell you when he/she needs to go to the toilet and go willingly? ______________________________________________________________
Can he/she manage his/her clothes themselves at the toilet? _________ What word(s) does he/she use for toileting? ______________________________

VII. SPEECH AND SLECTED MILDESTONES
Does child’s speech development appear normal? __________________ Does he/she talk well? __________________ Fairly well? _________________
Indistinctly? _________________ Not at all _________________ Stuttering? _________________ Other speech problems? _______________________
Major language spoken at home? ________________________________________________________________________________________________

VIII. SOCIAL RELATIONSHIPS
1. Child’s playmates: Neighbor children ________________________ Relative __________________________________________________________
                       Older than child __________________________ Younger __________________________________________________________
2. Does child appear to get along well with other children? ____________________________________________________________________________
3. Is he/she inclined to lead or follow activities in play? ______________________________________________________________________________
4. Does he/she have a pet? ____________ If so what? ____________________________________ Pet’s Name _________________________________
5. Has child had any travel experience? ____________ If so, where and how did he/she travel (car, plane, etc.)? _________________________________
___________________________________________________________________________________________________________________________

IX. PLEASE CHECK ALL OF THE FOLLOWING WHICH DESCRIBE BEHAVIOR YOUR CHILD OFTEN
DISPLAYS
Restlessness ____________ Excitability ____________ Aggressiveness ____________ Quarreling ____________ Nail biting ____________
Nose picking _____________ Thumb sucking ____________ Shyness ____________ Temper ____________ Worries/Fears ____________
Cries Easily ____________ Destructiveness (breaks things purposefully) ________________________________________________________________
If afraid of: Loud noises ___________________________________ The dark ________________________ Animals ____________________________

X. Please add any other information, which you feel, would be of help to us in better understanding your child.
Also, if you which, include specific goals (for your child and yourself) which you may have regarding your
child’s enrollment at UT Child Care Program.
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________

Approximate date you wish to enroll your child _____________________________________________________________________________________
Hours each day ___________________________ Time of arrival ___________________________ Time of departure ____________________________
Persons responsible for pick-up each day __________________________________________________________________________________________
Signature of parents ________________________________________________________________ Date ______________________________________
                     ________________________________________________________________ Date _____________________________________

                   Return to:
                          UT Child Care Program
                          Director
                          711 Jefferson Avenue
                          Memphis, Tennessee 38105
I have received a copy of the Day Care Licensing Regulations.
I have received a copy of UT Child Care Program Policies and Handbook.
I do hereby authorize emergency medical care____________________________________________________________________

								
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