Essential Child Information Form for Safe Care

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Child Information Form

Parent's Name(Required)

First Last

Parent's Email(Required)

Parent's Address(Required)

City State

Parent's County(Required)

Child's Name(Required)

First Last

Child's Date of Birth(Required)

MM slash DD slash YYYY

Child's Race/Ethnicity(Required)

Child's Gender(Required)

Child's Primary Language(Required)

If other, please explain

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Age

This field is hidden when viewing the form

Child race/ethnicy

Does your child have any allergies?(Required)

Yes

No

If yes, please list(Required)

Does child have any medical conditions or behavioral diagnosis?(Required)

Yes

No

If yes, please list(Required)

Has your child run away in the past?(Required)

Yes

No

If yes, please explain.(Required)

Is your child on medication?(Required)

Yes

No

If yes, please list and explain(Required)

Does your child have any birthmarks?(Required)

Yes

No

If yes, please list(Required)

Are immunizations up to date?(Required)

Yes

No

Date of Last Doctor Appointment

MM slash DD slash YYYY

This field is hidden when viewing the form

Last doctor appt

Child’s Primary Physician Name(Required)

Child’s Primary Physician Phone Number

Child’s Primary Physician Address

Does your child have health insurance?(Required)

Yes

No

Child's Type of Health Insurance?(Required)

Type of Medicaid(Required)

Child's Health Insurance Provider(Required)

Child's Health Insurance Member ID(Required)

Does your child attend school or daycare?(Required)

Yes

No

Child's current school or daycare center(Required)

Grade(Required)

Does your child have an IEP or 504?(Required)

Yes

No

If yes, please explain the accommodations(Required)

Does your child have a nickname?(Required)

Yes

No

Please share your child's nickname(Required)

What does your child like to do at home?(Required)

Does your child have any particular dislikes?(Required)

Yes

No

If yes, please explain.(Required)

Does anything scare your child?(Required)

Yes

No

What scares your child?(Required)

What are your child's favorite foods or formula?(Required)

Does your child have a feeding schedule?(Required)

Yes

No

What is the feeding schedule?(Required)

Does your child have a bedtime routine?(Required)

Yes

No

Child’s bedtime routine(Required)

What calms your child?(Required)

What motivates your child?(Required)

How do you manage challenging behaviors?(Required)

Is your child potty trained?

Yes

No

Diaper/Pull Up Size

Does your child swim?(Required)

Yes

No

Is your child of car seat age?(Required)

Yes

No

What type of car seat does your child use?(Required)

What size shirt does your child wear?

What size pants does your child wear?

What size shoes does your child wear?

Are there any immediate needs for your child?(Required)

Yes

No

If yes, please explain.

Date

MM slash DD slash YYYY

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