2013 gradual entry

CHILD'S STARTING DATE: ______/ ______/ ______ YY MM DD

SEX:

DATE OF BIRTH: ______/ ______/ ______ YY MM DD

M ____ F ____

NAME OF CHILD:______________________________________________________________________________________________

(Surname) e(Given Nams) (Also Known As)

Name the Child responds to: ____________________________________________________________________________________________ Address: ____________________________________________________________________________________________________________ Postal code:__________________________________________________ Phone: _________________________________________________ Person(s) with whom the child lives (adults and children):_____________________________________________________________________ Child's first language: ________________________________ Other languages: ___________________________________________________

Name: __________________________________ Home phone: _____________________________ Cell phone: ________________________ Work phone: ____________________ Days/hours of work: ________________________________ E-mail: ____________________________ Name: __________________________________ Home phone: _____________________________ Cell phone: ________________________ Work phone: ____________________ Days/hours of work: ________________________________ E-mail: ____________________________ Name: ___________________________________________________________________ Relationship to child: _________________________ Home phone: ____________________________ Work phone: ______________________________ Cell phone: _________________________ Name: ____________________________________________________________________ Relationship to child: ________________________ Home phone: ____________________________ Work phone: ______________________________ Cell phone: _________________________ Name: ____________________________________________________________________ Relationship to child: ________________________ Home phone: ____________________________ Work phone: ______________________________ Cell phone: _________________________ Name: ____________________________________________________________________ Relationship to child: ________________________ Home phone: ____________________________ Work phone: ______________________________ Cell phone: _________________________

Name: ____________________________________________________________________ Phone: ____________________________________

YES

NO

Comments:______________________________________________________________________________________

Toileting/Diapering (special words): _______________________________________________________________________________________ Rest Time (special comfort – toy/blanket): __________________________________________________________________________________ Eating/Mealtime (include food likes/dislikes): _______________________________________________________________________________

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