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A Little Bit About You

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Comments

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Family Information

Parent/Guardian Name(s):*

Home Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Primary Phone Number:*

Secondary Phone Number:

Emergency Contacts

Emergency Contact Name:

Phone Number:

Backup Emergency Contact:

Phone Number:

Medical Information

Pediatrician/Doctor Name:

Phone Number:

Preferred Hospital:

Emergency Instructions

Location of First Aid Kit:

Location of Fire Extinguisher:

Special Instructions:

House Rules

Allowed Activities:

Restricted Areas:

Discipline Guidelines:

Additional Notes

Inform Us About Your Kid

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Comments

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Parent/Guardian Name(s):*

Child’s Name 1*

Child’s 1 Age

Allergies & Medications

Food Allergies:

Environmental Allergies:

Medications (dosage & time):

Daily Routine

Meal Times:

Nap/Bedtime:

Homework/Study Time:

Screen Time Rules:

Important Notes

Comfort Items (toys, blankets, etc.):

Fears or Triggers:

Favorite Activities:

Do you want to add additional children?

Yes

Child’s Name 2*

Child’s 2 Age*

Allergies & Medications

Food Allergies:

Environmental Allergies:

Medications (dosage & time):

Daily Routine

Meal Times:

Nap/Bedtime:

Homework/Study Time:

Screen Time Rules:

Important Notes

Comfort Items (toys, blankets, etc.):

Fears or Triggers:

Favorite Activities:

Child’s Name 3 (Optional)

Child’s 3 Age (Optional)

Allergies & Medications

Food Allergies:

Environmental Allergies:

Medications (dosage & time):

Daily Routine

Meal Times:

Nap/Bedtime:

Homework/Study Time:

Screen Time Rules:

Important Notes

Comfort Items (toys, blankets, etc.):

Fears or Triggers:

Favorite Activities:

Child’s Name 4 (Optional)

Child’s 4 Age (Optional)

Allergies & Medications

Food Allergies:

Environmental Allergies:

Medications (dosage & time):

Daily Routine

Meal Times:

Nap/Bedtime:

Homework/Study Time:

Screen Time Rules:

Important Notes

Food Allergies:

Fears or Triggers:

Favorite Activities: