New Family Questionnaire — Whitney's House

About Your Child

Child's full name

Nickname or what they're called at home

Birthday

Pronouns

Languages spoken at home

Parents & Guardians

Parent / guardian 1 — name

Pronouns

Relationship to child

Cell phone

Work phone

Employer / occupation

Parent / guardian 2 — name

Pronouns

Relationship to child

Cell phone

Work phone

Employer / occupation

Home address

Care Schedule

Anticipated start date

Days and hours of care needed

Emergency Contacts (other than parents)

Contact 1 — name

Relationship to child

Phone

Authorized for pick-up?

YesNo

Contact 2 — name

Relationship to child

Phone

Authorized for pick-up?

YesNo

Authorized Pick-Up List

Only the people listed here (or added later in writing) may pick up your child. Photo ID may be requested.

Name

Phone

Name

Phone

Name

Phone

Medical Information

Physician name

Physician phone

Preferred hospital

Health insurance provider

Allergies (food, medication, environmental)

Current medications and dosage instructions

Chronic conditions or medical needs

Dietary restrictions

Routines at Home

What does a typical morning look like?

Nap and sleep routine

Evening / bedtime routine

Diapering or toileting — where are you in the process?

Food & Eating

Favorite foods

Foods to avoid, allergies, or sensitivities

How does your child usually eat? (independently, with help, still nursing / bottle, etc.)

Comfort & Personality

Comfort items — lovies, blankets, pacifiers

What helps your child when they're upset or overwhelmed?

Tell me about your child's personality — what lights them up?

Any fears, sensitivities, or things that are hard for them right now?

Play & Interests

Favorite toys, books, songs, or characters

Favorite outings and activities as a family

Do you have pets at home? What are their names?

Your Village

Who is in your village? Grandparents, aunts, uncles, close friends — tell me about them.

Consents & Authorizations

I authorize Whitney's House to seek emergency medical treatment for my child, including transport to the nearest emergency facility, if I cannot be reached.

YesNo

I authorize the use of sunscreen and insect repellent as needed.

YesNo

I authorize occasional photos of my child for classroom documentation and family communication (e.g. the WhatsApp group).

YesNo

I would like to opt into following Whitney's location.

YesNo

Notes or exceptions to the above

Anything Else

Anything else you'd like me to know about your child or family?

This information is kept private and shared only with Whitney.