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 !