Email* First Name* Last Name* Name that your child likes to be called* Siblings/Ages Child’s Personality and Special Instructions: (easily stimu-lated, needs quiet environment, peek-a-boo, toys that make noise)* Is your child prone to diaper rash? Yes No If yes, did you provide diaper cream for child? Special Instructions regarding application of diaper cream? Please list any dietary or other conditions that would cause your child’s stools to be abnormal even when (s)he is in good health?* Does your child have special words or gestures to communicate things that the teacher might not readily under-stand? If so, explain: Does your child like to be swaddled? Yes No Does your child sleep with anything special? (i.e blanket, stuffed animal,etc.) Yes No

When does your child typically nap and for how long?* What is your normal routine for putting baby down for naps? (rocking, and lullabies, patting in crib, etc.)* What techniques do you find are most effective for calming your child when he/she is upset (rocking, singing a special song, etc.)? Does your child use pacifier suck thumb Special directions? (only at naps, etc) Is your child on breast milk formula Does your child prefer their milk warm at room temp How many oz. does your baby typically consume at feedings? How many hours between feedings? Is your child on infant cereal pureed solids (baby food) How much does your child typically eat at each meal? Please list any additional information your child’s teacher might need to know about your child’s eating habits or meal preparations? Do you follow a * baby-led schedule time-led schedule Please write down a typical day for your child with general nap times and feeding times? *