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ELC Developmental History and Background Information
Please verify reCaptcha before submitting the form.
Please note: All field are required. Please type N/A if info is not applicable.
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Child's Name
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Child's Date of Birth
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Parent Email
Developmental History
Please provide information for Infants & Toddlers (marked*) as appropriate to the age of your child.
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Age began sitting?
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Age began walking?
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Age began crawling?
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Age began talking?
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Does your child have any speech difficulties?
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Does your child have any special words to describe his/her needs?
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What language is spoken at home?
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Is there any history of colic?*
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Does your child use a pacifier or suck thumb? If so, when?*
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Does your child have a fussy time? If so, when?*
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How do you handle this time?*
Health
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Any known complications at birth?
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Serious illnesses and/or hospitalizations?
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Special physical conditions, disabilities?
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Allergies (i.e., astham, hay fever, insect bites, medicine, food reactions)?
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Regular Medications?
Any medications to be administered at school requires an additional form signed by licensed physician.
Eating Habits
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Special characteristics or difficulties?
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Favorite Foods?
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Foods Refused
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Does your child eat with a spoon?*
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Does your child eat with a fork?*
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Does your child eat with a hands?*
Toilet Habits
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Are disposable or cloth diapers used?*
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Is there a frequent occurrence of diaper rash?*
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Do you use oil, powder, lotion and/or other?*
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Are bowel movements regular?*
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How many per day?*
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Is there a problem with diarrhea?*
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Is there a problem with constipation?*
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Has toilet training been attempted?*
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Please describe any particular procedure used for diapering or toileting to be used at Temple Beth Avodah.*
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Is a potty chair used at home?*
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Is a special child seat used at home?*
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Is a regular seat used at home?*
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How does your child indicate bathroom needs? Please include specific words.*
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Is your child ever reluctant to use the bathroom?
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Does your child have accidents?
Sleeping Habits
Please note: The American Academy of Pediatrics has 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 under one year of 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.
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When does your child go to bed at night?
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When does your child get up in the morning?
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Describe any special characteristics or needs (stuffed animal, story, mood on waking etc.)
Social Relationships
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How would you describe your child?
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Previous experience with other children/day care.
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Reaction to strangers.
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Is your child able to play alone?
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Favorite toy and activity?
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Fears (the dark, animals, etc.).
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What is the method of behavior management/discipline used at home?
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What would you like your child to gain from this childcare experience?
Daily Schedule
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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.
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Is there anything else we should know about your child?
Signature & Date
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By typing my name below and clicking "Submit" I hereby constitute that this is my electronic signature for legal purposes.
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Date
Fri, April 26 2024 18 Nisan 5784