Procare

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Bright Beginnings

980 Enfield St, Enfield, CT, 06082

Student #1

First Name

Last Name

Date of Birth

Allergies

Medication Needs

preferred hospital

Childs Address

town

state

who does your child live with?

if other please explain

Program

Program start date

School attending ( if school age)

will transportation be required?

Please list any brothers and/or sisters. please indicate their age, gender and whether or not they live with the enrolled child for each sibling.

Please list any other person(s) living with the child and their relationship (if any) to the child:

Is your child right or left handed?

Has this child had any previous group and/or school experience?

What word does your child use for toileting?

Does your child or have they ever had or suffered from bowl or bladder infections?

Does your child have any special food or eating instructions?

Any additional information such as discipline, child's communication, comforting, etc?

Were there any problems during pregnancy or delivery of your child? if yes please explain.

What was your Childs weight at birth?

Does your child have any skin diseases? if yes please explain.

Has your child had any hospitalizations since birth? If yes please explain

Child's history of illness/ injuries (please select all that apply)

Has your child had any Other illness? if yes please explain.