Monday off registration form

    Name :

    Birthday :

    Age :

    Address :

    City :

    Postal code :

    PRACTITIONER:

    Referring organization :

    Group :

    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 !