Child's Enrollment Form Pilgrim Child Care & Preschool (PCCP) PCCP | PO BOX 121 | DUXBURY, MA 02331 PCCP Children Papers Packet for: Child's Name DOB MM slash DD slash YYYY Dear Parents, Welcome to PCCP. Please complete the enclosed forms for your child's file. Please send the last 3 pages of this packet to your child’s Pediatrician, especially if your child has an allergy or any health provision. One form is optional for medication; one is for allergies/health provisions; and one for (which each child MUST have on file) is the Physician’s Statement form. Return this completed packet at least 1 month before your child’s 1st day OR at your earliest convenience. A parent signature is needed on each form. The PCCP doors control the access requiring a code is entered to unlock the doors. The code is given to parents upon enrollment and parents are asked to limit sharing this code to one alternative pick up person if possible. There is also a bell to ring should for guests and visitors. If you have any questions about the packet, use of the door code, enrollment, or tuition, please contact either Michelle or Dawn. Thank you. Michelle L. Manganaro, PCCP Director, 781-934-8145, ext. 211 Email: michellemanganaro@gmail.com Dawn Kerivan, PCCP Financial Coordinator, 781-934-8145, ext. 200 Email: DKatpilgrim1@verizon.net Form required by: THE COMMONWEALTH OF MASSACHUSETTS Department of Early Education and Care Child InformationChild's Name DOB MM slash DD slash YYYY Age at Admission Date of Admission MM slash DD slash YYYY Home Phone Number Primary Language Identifying Marks Eye Color Hair Color Skin Color Sex Height Weight Parent/Guardian InformationParent/Guardian Name First Last Relationship to Child Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reachable Day Phone NumberEmail Adress (at least one per family) Business Name Town Business Phone Number Hours at Work Parent/Guardian First Last Relationship to Child Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reachable Day Phone Number Email Adress (at least one per family) Business Name Town Business Phone Number Hours At Work Child's Physician Phone Number Physician's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Does your child have an Allergy/Special Diets or a Continual Health need?(Required) Yes No If yes, list here briefly and explain on IHCP form in this packet (Physician signature required) Are there any custody agreements, court orders, and restraining orders pertaining to the child? Yes No If yes, please give copies to the Director prior to the child's first day documents to be provided: Are there any other special limitations or concerns the Teachers should know about your child? Yes No If yes, please explain: Parent/Guardian Signature Date MM slash DD slash YYYY Regulations for licensing require this information to be on the file to address the needs of children while in care. Child's Name Date of Birth MM slash DD slash YYYY Please provide information for children under 3 (marked*) as appropriate to the age of your child. Developmental History*Age began sitting: *Crawling: *Walking: *Talking: *Does your child pull up? *Crawl: *Walk with support? Any speech difficulties? Special words to describe needs Language spoken at home *Any history of colic? *Does your child use a pacifier or suck thumb? *When? *Does your child have a fussy time? *When? *How do you handle this time? HealthAny known complications at birth? Serious illness and/or hospitalizations: Special physical conditions, disabilities: Allergies i.e. asthma, hay fever, insect bites, medicine, food reations:(Required) Regular medications: Eating HabitsSpecial Characteristics or difficulties: Number*Infant is on a special formula, describe it's preparation in detail: Favorite food: Foods refused: *Is your child fed held in lap? High Chair? *Does your child eat with spoon? Fork? Hands? Toilet Habits*Are disposable or cloth diapers used? *Is there a frequent occurence of diaper rash? *Do you use:OilPowderLotionOtherIf you chose other, please specify: *Are bowel movements regular? *How many per day? *Has toilet training been attempted? *Constipation? Please describe any particular procedure to be used for your child at the center: *What is used at home? Potty Chair Special Child Seat? Regular seat? How does child indicate bathroom needs (include special words): Is your child ever reluctant to use the bathroom? Does your child have accidents? Sleeping Habits*Deos your child sleep in a crib? Bed? Does your child become tried or nap during day (include when and how long)? Please note: The American Academy of Pediatrics had determined that placing a baby on his/her back to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden and unexplained death of a baby one year age. If your child does not usually sleep on his/her back, please contact your pediatrician immediately to discuss the best sleeping position for your baby. Please also take the time to discuss your child's sleeping position with your caregiver. When does your child go to bed at night? Get up in the morning? Describe any special characteristics or needs (stuffed animal, story, mood on waking etc) Social RelationshipsHow would describe your child? Previous experience with other children/day care: Reactions to strangers: Able to play alone? Favorite toys and activities: Fear (the dark, animals, etc.): Fears (the dark, animals, etc.): How do you comfort your child? What is the method of behavior management/discipline at home? What would you like your child to gain from this childcare experience?Please describe your child's schedule on a typical day. For infants, please include awakening, eating, time out of crib/bed, napping, toilet habits, fussy time, night bedtime, etc.Is there anything else we should know about your child?Parent/Guardian Signature Date MM slash DD slash YYYY
