Monday off registration Name : Birthday : Age : Address : City : Postal code : PRACTITIONER: Referring organization : Practitioner’s name : Telephone number : Email adress : Date of respite care : Need for transport : YesNo PARENTS INFORMATION : Mother's name : Phone Number : Other : Email : Father's name: Phone Number: Other : Email : PERSON AUTHORIZED TO PICK UP THE CHILD: Name : Relationship : Phone Number: Name : Relationship: Phone Number: IN CASE OF EMERGENCY : Name : Relationship : Phone Number : ALIMENTATION : Able to eat alone ? YesNo Favorite food : Food dislike : ALLERGY : Allergy ? YesNo Information : Epipen ? YesNo CLEANLINESS : Is the child in diapers ? YesNo Does he wear Pull-Ups ? YesNo MOTRICITY : Can he walks ? YesNo Can he sits alone ? YesNo LANGUAGE : Spoken language at home : Understood language : Communicate : WellWith difficultyA little Note : SOCIALIZATION : Can he speak easily ? YesNo Is he aggressive ? YesNo Does he do a seizure ? YesNo It is the first time he's being looked after ? YesNo NAP : Does he normally have a nape in the day ? YesNo If yes, When ? How long ? Does he need a blanket, a pacifier or a plush to sleep ? KNOWLEDGE OF THE CHILD AND HIS HABITS : Has he already been to a daycare ? YesNo Everything went well ? YesNo Brothers ? Sisters ? Do you have a pet ? YesNo Favorites activities ? (Book, toy, game) Is he used to play with other children ? YesNo What is his temperament? (Joyful, lone, energetic, shy...) Have some big changes happen to the child lately ? Is the child in a special learning period ? What comforts or calms him ? AUTHORIZATION : To take picture ? YesNo To put sunscreen ? YesNo To go outside ? YesNo Question or comment ?: Thank you for your cooperantion with us for the better for your kids !