Details of Minded Child form

To be completed and signed by the parent/guardian/carer and given to the childminder.

Name of child: _______________________________________________________________

Name child likes to be called: ___________________ Date of birth: ____________________

Address: ___________________________________________________________________

_____________________________________ Home tel no: __________________________

Parent/s names: ______________________________________________________________

Parent/s address and phone number if different from above:__________________________

___________________________________________________________________________

Parent/s work address: ________________________________________________________

___________________________________________________________________________

Tel no’s including mobile numbers: ______________________________________________

Email address: _______________________________________________________________

Parent/s work address: ________________________________________________________

___________________________________________________________________________

Tel no’s including mobile number s:

______________________________________________

Email address: _______________________________________________________________

In the event of an emergency who can be contacted if parents cannot be reached:

Name of emergency contact: ___________________________________________________

Address: ___________________________________Tel no’.s:

_________________________

_________________________________________________________________________

Names of individuals that may be collecting your child: ______________________________

Drs. name and address: ________________________________________________________

_________________________________Tel no: ____________________________________

Is your child receiving any long term medication/treatment? __________________________

If yes, what medication/treatment? _______________________________________________

2012-10-25
Details of Minded Child form
Are there any side effects from medication/treatment prescribed? _____________________

If yes, what are they? _________________________________________________________

Is your child allergic to any medication?

___________________________________________

Allergies, special diet, health problems, childhood illnesses ___________________________

___________________________________________________________________________

Does your child have any additional needs/special needs/ disabilities. If so please give
details:_____________________________________________________________________

Immunisations/vaccinations: Has your child been fully immunised against:

Diphtheria Whooping cough  Tetanus  Polio 

MMR  Hib Meningitis 

Has your child ever been admitted to hospital? _____________________________________

If yes, please give dates, details etc

_______________________________________________

___________________________________________________________________________

Language/s spoken at home: ____________________________________________________

Religion:
____________________________________________________________________

How would you describe your child’s ethnicity? ____________________________________

Has your child been in any other childcare setting before? ____________________________

If yes, why did she/he leave?____________________________________________________

Were there any difficulties with the placement? ____________________________________

If yes, please give details

_______________________________________________________

Anything else your childminder should know about your child e.g. fears, dislikes, comfort
items, special words e.g. for items of food, needing the toilet, or wanting to sleep, significant
events:
___________________________________________________________________________
Parents should notify the childminder of any changes to these details immediately.
Details of any accidents which occur while the child is in the care of the childminder
should be recorded and signed by the childminder and countersigned by
parent/guardian/carer.

2012-10-25