Child's Information

Child's Full Legal Name (First, Middle, Last)

City and State of Child's Birth

Child's Primary Address

Primary Language(s) Spoken to the Child

Parent/Caregiver 1 Information

Parent/Caregiver 1 Relationship to Child

Parent/Caregiver 1 Home Address

Please type "same as child" if applicable.

Parent/Caregiver 1 Email

Parent/Caregiver 1 Occupation

Write N/A if not employed.

Parent/Caregiver 1 Employer

Write "self" if self employed. Write N/A if not employed.

Parent/Caregiver 2 Information

Parent/Caregiver 2 Relationship to Child

Parent/Caregiver 2 Home Address

Please type "same as child" if applicable.

Parent/Caregiver 2 Email

Parent/Caregiver 2 Occupation

Write N/A if not employed.

Parent/Caregiver 2 Employer

Write "self" if self employed. Write N/A if not employed.

Alternate & Emergency Contacts

Emergency Contact

Please provide the name, phone number, address and relationship to the child of the primary emergency contact to be contacted in the event that no primary parent/caregiver can be reached.

Please provide the names, addresses, and phone numbers of any persons (excluding parent/caregivers as defined above) authorized to drop off or pick up your child from care. Please also include their relationship to the child.

Are there any persons who should never attempt to pick up from or make contact with Phoenix House?

If so, please share their full name and a brief description of any risk they may pose to the child (non custodial parent, etc.)

Health & Safety

Please provide the name, phone number, and address of your child's pediatrician.

Please provide the name, phone number, and address of your child's dentist.

Be advised that the best practice recommendation for optimal dental health is that you should make an appointment for your child's first dental visit as soon as their first tooth comes in or by their first birthday, whichever comes first.

Is your child up-to-date with their immunizations in accordance with recommendations made by the Centers for Disease Control and Prevention (CDC)?

In the unlikely event of an emergency where a Phoenix House staff member has to transport your child to the hospital or advise emergency personnel on where your child should be transported, what is your preferred hospital?

Be advised that Phoenix House strongly recommends Rady Children's Hospital Emergency Center (3020 Children's Way, San Diego, CA 92123) for true medical emergencies.

Does your child take any medications regularly? If so, will Phoenix House staff ever be required to administer these medications?

Please provide the name/dose of any prescribed medications as well as the frequency taken. If you child does not take any medications, please type "N/A".

Does your child have any food intolerances?

Please list any foods that seem to make your child break out in a rash or have an upset stomach. Please also provide a description of the protocol that should be taken if a child accidentally ingests a food that they are intolerant of. If you child does not have any food intolerances, please type "N/A".

Does your child have any allergies?

Please only include true allergies (not suspected or confirmed intolerances) and provide a rating of the allergy severity using this scale (mild, moderate, severe, very severe). Please also provide a description of the protocol that should be taken if a child accidentally encounters or ingests something that they are allergic to. If your child does not have any allergies, please type "N/A"

Does your child have any physical support needs or disabilities that impact their day-to-day quality of life?

Does your child have any medical conditions or special needs?

If so, please describe below. If not, please type "N/A".

Child's Routine

What experience has your child had thus far with other childcare providers outside of care provided by their immediate parents/caregivers?

Please include information on if the child has ever been enrolled in a daycare or childcare center before, if the child has had a nanny/consistent babysitter, if Phoenix House will be the child's first experience with childcare outside of the home, etc.

Does your child nap between 9am-4pm for at least one 90 minute stretch per day?

Please describe your child's nap routine.

Include details about when, for how long, where and how (with a sleep sack, a lovey, a light blanket, in the dark, with a nightlight, etc.) your child prefers to nap.

Please describe your child's diaper/toileting routine.

Please use this space to share how often you change your child's diaper, how often they use the toilet how confident they are in using the toilet (do they need help getting up to a standard sized toilet, do they need help wiping, do they prefer privacy, etc.). Please share any insight on routines your child is familiar with in this department. Do they like to sing a song/read a book while on the toilet or hold a toy on the changing table? Do they ever seem shy/anxious? All information in this domain is helpful.

Does your child have anything that brings them comfort/security that their Phoenix House caregivers should know about?

This could be a pacifier, favorite words or phrases, routines, etc.

Drop-In Care Enrollment Questionnaire

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