Use of form: This form is mandatory for family child care centers to comply with DCF 250.09(1)(c)1. and for certified providers to comply with 202.08(12)(g). Failure to comply may result in issuance of a noncompliance statement. This form is voluntary for group child care centers; however, it meets the requirements of DCF 251.09(1)(am). This form collects information about children under 2 years of age in order to aid child care workers in individualizing the program of care for the child in a family or group child care center. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].

Instructions: This form is to be completed by a parent / guardian and must be on file at the center prior to a child's first day of attendance. Regular updates can be noted. This form should be kept in the room where care is provided. If additional space is needed, attach a separate sheet.

HEALTH Note: Health conditions that may affect the care of the child must be recorded on the department’s form, Health History and Emergency Care Plan. The form should be shared with any person who provides care for the child.

MEALS

Sleep position – child under age 1 year

Note: Children under age 1 year must be placed to sleep on their back unless a written statement from the child's physician is attached.

DIAPERING / TOILETING

VERBAL COMMUNICATION

COMFORTING

SELF-EXPRESSION

PHYSICAL AND SOCIAL DEVELOPMENT

MISCELLANEOUS

By providing complete information about your child, you will be assisting staff in creating a positive experience for him / her while in care. List any information about your child's habits, abilities, or personality that you feel will be helpful to the staff while caring for your child.