Please print out the following application form and mail it to:
The Toddler Program, 3509 Pahoa Ave., Honolulu, HI 96816
(808) 735-3197 Fax: (808) 737-9833
Please include $30 with your application.
|
The Toddler Program APPLICATION FORM General Information Name of Child Last_______________________ First ______________________ Middle____________ Nickname (If Any) _______________________________ Birthday _____________________________ Home Address ____________________________________________________________________________ City ___________________________________ Zip Code ____________ Home Phone # _________________ Birth Certificate Number _____________________________ Father's Name _____________________________________ Occupation _____________________________ Business Address __________________________________________________________________________ Phone #'s Business ________________ Cell _______________ Pager _______________ Fax ____________ Mother's Name _____________________________________ Occupation _____________________________ Business Address __________________________________________________________________________ Phone #'s Business ________________ Cell _______________ Pager _______________ Fax _____________ List the other members of your household: Name Relationship Age ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Have any siblings attended The Toddler Program? NO_______ Yes/Date _______________________________ How did you hear about The Toddler Program? _____________________________________________________ |
| Development History
(Please answer the questions below to the extent that they are applicable.) When did your child start crawling? _______months Walk? ________months Talking? ________months Does your child have frequent colds? Yes ______ No ______ How many in the last year? ______ Does your child have nay serious/severe illness or injury? Yes ______ No ______ If yes, please explain further: _________________________________________________________________ Does your child have any allergies that we should be aware of? Yes ______ No ______ If yes, please explain further: _________________________________________________________________ |
| Daily Routine
What time does your child wake up? __________ Go to sleep? __________ Does your child nap during the day? Yes _____ No _____ If yes, what time and for how long? ______________ Does your child sleep well? _________________________________________________________________ What is your child's diet pattern (food preferences) at: Breakfast: ______________________________________________________________________________ Lunch:_________________________________________________________________________________ Dinner: ________________________________________________________________________________ List any food dislikes or eating problems: ______________________________________________________ List any toilet problems: ____________________________________________________________________ Are bowel movements regular? Yes _____ No _____ If yes, when do they usually occur? __________________ Word used for bowel movement: _____________________ Word used for urination: ____________________ Describe your child's health:_________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Describe your child's personality:_____________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ How does your child get along with family members?________________________________________________ ________________________________________________________________________________________ What play group experiences does your child have?_________________________________________________ ________________________________________________________________________________________ Does your child have any special problems or fears?________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ What is your plan for care when your child is ill?___________________________________________________ ________________________________________________________________________________________ _________________________________________________________________________________________ |
| Emergency Information (In
case of emergency, whom should we contact?)
Name Address Phone Relationship _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________
|