CCC Child Information

This form is filled out for each child.

*Address Line 1
Address Line 2
*Zip/Postal Code
*Child's Full Name:
Name They Would Like To Be Called:
*Date of Birth:
Child's Nationality:
*Child's T-Shirt Size:
Previous school or day care attendance:
Describe your child's personality:
What goals do you have for your child this year in preschool?:
Father's Name:
Father's Cell Number:
Father's Occupation:
Father's Place of Employment:
Father's Nationality:
Mother's Name:
Mother's Cell Number:
Mother's Occupation:
Mother's Place of Employment:
Mother's Nationality:
Do both parents have custody of this child?:
If no, please explain.:
Siblings names and ages.:
Pets and Pets Names:
Does your family attend church?:
If yes, which church?:
If I cannot be reached in an emergency, the following person is authorized to act in my behalf:
Name of Person:
Relationship to Family:
Emergency Contact Phone Number:
Many hospitals and doctors will not treat a child without a parent's consent. If we are unable to contact you or your emergency contact person, do you grant permission for CCC to seek emergency treatment?
*Consent to Treat?:
Name of Doctor:
Doctor's Phone Number:
Health Insurance Company:
Policy Number:
Hospital of Choice:
List any known allergies your child may have::
List anything in your child’s medical history that the teacher should be aware of::
List any special needs that may help your child’s teacher better understand your child::
Toilet habits: Is your child potty trained? Do they need help?:
What terminology does your child use regarding the use of the bathroom?:
How does your child react to “accidents?”:
Eating habits and difficulties::
What foods does your child like?:
What foods does your child dislike?:
Typical Bedtime:
Typical Naptime:
How do you get your child to sleep?:
Naptime securities (pacifier, bottle, blanket. animal)::
Behavior habits (biting nails, sucking fingers, tantrums, biting others, stammering, etc.)::
Does your child have any unusual fears? Do you know the cause?:
What is your child's reaction to strangers?:
Does your child cry easily? If so, why?:
Is it easy for your child to be separated from either parent?:
What types of discipline are used in the home?:
List special interests and toys::
*I understand that ClearView Children’s Center is not required to be licensed by the state as a child care agency.:
*Parent Signature
*Today's Date: