Background Information sheet

Background Information Form

Starting Date:  
Child's Name:     Date of Birth:     
Mothers Name:     Contact Number:  
Fathers Name:     Contact Number:  
Languages spoken at home:     Religion:  
Key phrases from home language or unique words used by child  
Does your child celebrate:   Christmas   Easter   Birthdays   Any others:  
Family Structure: (i.e. 2 parent, single parent, working etc):  
Position in Family:    Any Nicknames:  
Does your child have any allergies? :   None known   Yes   Please specify:  
Does your child have regular medication? :   No   Yes   Please specify:  
Does your child have Asthma?:   No   Yes   If yes did you complete an asthma plan?   No   Yes
Does your child have any additional needs?:   No   Yes   Please specify:  
Child's Interests:  
Does your child have any fears:  
Any individual needs/talents (i.e. speech therapists, support teachers, gifted programs etc):  
Strategies used to guide your child's behaviour:  

Daily Living

Does your child have any special dietary needs eg vegetarian, religious beliefs?
What is your child's typical eating pattern?
Write N/A (not applicable) if your child is too young for the following questions to apply.
What foods does your child like?    Dislike?  
How well does your child use table utensils (cup, fork, and spoon)?
Is your child  in nappies  being toilet trained?  needs reminding?  independent in toileting?
How does your child indicate bathroom needs?  
What is your child's regular sleeping patterns?  
Awakes at  Naps at  Goes to bed at  
What help does your child need to get dressed?  
Emergency Contact and Authority to collect
In the case of an emergency, if we are unable to contact either parent, please indicate at least two people who we can contact to act on your behalf. These people will also be authorised to collect your child.
  Person 1 Person 2 Person 3
Is this person authorised to consent to medical treatment of, or to authorise administration of medication to, your child?
Is this person authorised to authorise an educator to take the child outside the education and care service premises? Eg: excursions
First Name
Last Name
Home phone
Mobile phone
Work Phone
Relationship to child
Please note: Before any authorised person listed above is permitted to collect your child from our centre photoidentification will be required. You may change or add to this list at any time.
Days attending Wiggles and Giggles:
Monday Tuesday Wednesday Thursday Friday