Prospective Family Questionnaire

Name: _______________________________________
Address: ______________________________________
Phone #: ____________________________
Childs Name: _________________________
Days Needed (please circle all): M T W Th F

Start Date:_________
Hours Needed: ___ AM to ___ PM

How did you hear about this daycare?: _________________________

Is child currently in daycare?: YES / NO

If yes, reason for leaving current daycare:
__________________________________________________________
__________________________________________________________
If no, where does child currently spend his/her daytime?: ____________________
How many daycares has your child attended?: ____________
Does your family have any outstanding childcare debts? _______________

Child currently lives with: MOM /

DAD /

BOTH /

OTHER

Does Child have any siblings/half-siblings/step-siblings? ___________________

Circle all words that describe your childs personality:
SERIOUS / HAPPY / QUIET / MOODY / POLITE / ARTISTIC / INDEPENDENT /
PLAY ALONE / COMPASSIONATE / ENERGETIC / OUTGOING / PATIENT /

ENTHUSIASTIC / HONEST / TALKATIVE / EMOTIONAL / LEADER / SHY / ANGER

OUTBURSTS / FRIENDLY / ACTIVE / PERFECTIONIST / LOUD / THINKER /
AFFECTIONATE / INTENSE / ADVENTUROUS / LAID BACK / EAGER /
SENSITIVE / AGGRESSIVE / AFRAID
Describe a typical days schedule: ________________________________________
____________________________________________________________________
____________________________________________________________________
Does your child nap? YES / NO
If yes, what is the typical naptime: _____ to _____
How do you get them to sleep?: ____________________________________
What are some of your childs favorite toys?: __________________________
______________________________________________________________
How do you discipline at home?: ____________________________________
_______________________________________________________________
Do you use a reward system?: YES / NO
Is your child a good eater?: YES / NO
Any known allergies or foods you do not want your child to eat?: _________________
Can your child use the restroom independently?: YES / NO
If no, what does your child need help with? _________________________
Any known health problems?: _____________________________________________
Any reason to restrict activities?: __________________________________________
Anything else I should know about your child?: ______________________________
___________________________________________________________________
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