Mini-Minders Online Registration Form
*Tip - hit TAB to move to the next box, or SHIFT+TAB to move back 1 box
Child's Name
Mother's Name
Father's Name
Mailing Address
Home Phone
E-mail
*required
Daycare Arrangement
Days Required
Mon.
Tues.
Wed.
Thurs.
Fri.
Hours Required
1
2
3
4
5
6
7
8
9
10
11
12
AM.
PM.
to
1
2
3
4
5
6
7
8
9
10
11
12
AM.
PM.
School Attending
Start Date
Before/After School
Emergency Contact Information
Mother's Contact Information
Company
Address
Occupation
Phone
Father's Contact Information
Company
Address
Occupation
Phone
Child's Health Card #
Physician
Phone
Address
Authorized Alternate Contact
Parent Questionnaire
How did you find out about Mini-Minders?
What previous daycare experience has your child had?
No pets in the home?
Have you established a routine for your child?
Does your child have any allergies?
How is your child's health? Medical problems?
Is your child on medication?
Does your child have any fears?
Does your child wear cloth or disposable diapers?
Does your child have a learning disability?
Does your child prefer to sleep in a playpen? Bed?
What illnesses has your child been exposed to?
What concerns do you have in regards to discipline?
Does your child have feeding problems?
Does your child have a good appetite?
Are there particular foods you do not wish your child to eat?
Does your child have a sleeping problem?
Are there any special toys or blanket
s your child likes to sleep with?
Does your child usually fuss when you leave?
How do you calm your child down if he/she is upset?
What activities do you expect your Provider to offer
your child?
Will you be able to offer consistency in drop off and pick-up times?
Does your child socially interact well with other children?
Will you give consent to transporting your child in a licensed vehicle?
Office Use Only
Fee Enclosed
________
Medical Received
________
Child Admitted
________
Agreement Signed
________
Child Discharged
________
Agreement
By submitting the form above, you agree that all information provided is both accurate, and truthful. Upon receipt of registration, you will be contacted within a 48 hour period. Upon acceptance, your registration will be reviewed entitling you to an interview with a Provider. A registration fee of $35 will be charged after the interview.
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