FORM 1 Saint Joseph Child Development Center
San Jose , San Vicente Camarines Norte
REGISTRATION FORM
Instructions: This form is to be filled up by the parent/guardian of the child
upon enrolment to the Child Development Center. This will be kept by the Child
Development Teacher in the portfolio of the child.
Name of Gender:
Child:
Address : Birthda
y:
Guardian: Relations
hip:
Registered: No Age:
Yes
Child’s First Second
Language: Language:
Guardian Information : E-mail
address:
Mother:
Name: Occupatio
n:
Address:
Contact Home: Work:
Number:
Father:
Name: Occupatio
n:
Addres
s:
Contact Home: Work:
Number:
IN CASE OF EMERGENCY, Please contact the following :
Name: Relations
hip:
Contact Home: Work:
Number:
Accomplished
by :
Signature over printed name of Date
parent/guardian
Reviewed by: EMMA D. DIONEDA
Signature over printed name of Date
CDW
Registration Form Page 2
FORM 2
PHYSICAL HEALTH INVENTORY FORM
Instructions to Parents/Guardians: The following information is required to a
child attending the CDC for record and referral purposes. Please complete Part
I of the Health Assessment Form. Part II must be completed by a private
licensed physician/nurse, Municipal/Rural/Barangay Health Unit Officer
(M/R/BHUO), or Barangay Nutrition Scholars (BNS). The Center ensures that
each child has access to a thorough health assessment
BASIC INFORMATION
Child’s
Last First Middle
Name:
Birth Date: Se M F
x:
Address:
Parent/Guardian
Name(s)
Relations
hip:
Phone Work: Home:
Number(s):
Mobile
Number(s):
Accomplished by : ______________________________ __________________
Signature over printed name of parent/guardian Date
Reviewed by: EMMA .D. DIONEDA __________________
Signature over printed name of CDW Date
PART I – PHYSICAL HEALTH ASSESSMENT
To be completed by parent or guardian
Where do you usually take your child for
routine check-up?
Name of
Hospital/Center:
Addres Phone
s: No.
When was the last time your child had a routine check-up? (mo/day/yr) &
Where?
Date: Name of
Hospital/Center:
ASSESSMENT OF CHILD’S HEALTH – To the best of your knowledge has your
child had any problem with the following? Check () Yes or No and provide a
comment for any YES answer.
YE NO Comments (required for any YES
S answer
Allergies (Food, Insects,
Medicine, etc.)
Asthma
Bleeding
Bowels
Coughing
Diabetes
Ears or Deafness
Eyes or Vision
Other (please indicate)
Does your child take medication (prescription or non-prescription) at any time?
Yes No, name(s) of medication(s): _____________________________________
Does your child receive special treatment? (nebulizer, etc.)
Yes No, type of treatment: ____________________________________________
Does your child ever have a serious accident? Yes No, If yes describe
briefly:
________________________________________________________________________
I ATTEST THAT ALL INFORMATION PROVIDED ON THIS FORM IS TRUE AND
ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND IT
IS FOR CONFIDENTIAL USE IN MEETING MY CHILD’S HEALTH NEEDS IN CDC.
Signature of Parent/Guardian Date
PART II – CHILD PHYSICAL HEALTH ASSESSMENT
To be completed ONLY by Physician/Nurse Practitioner,
Municipal/Rural/Barangay Health Unit Officer or Barangay Nutrition Scholar
1. Does the child have diagnosed medical condition?
No Yes, describe:
2. Does the child have health condition which may require EMERGENCY
ACTION while s/he is in the Center? (e.i. seizure, allergy, asthma, bleeding
problem, heart problem, or other problem) if yes, Please DESCRIBE and
describe emergency action(s).
No Yes, describe: ______________________________________________
_____________________________________________________________________
3. Physical Examination Findings ____________________________________________
_____________________________________________________________________
Health Area WNL ABNL
Not
(With Normal Limits) (Abnormal)
Evaluated
Allergy
Asthma
Attention Deficit/Hyperactivity
Bowel/Bladder
Cardiac/murmur
Dental
Endocrine
ENT
Hearing
Musculoskeletal/orthopedic
Neurological
Nutrition
Physical Illness/Impairment
Respiratory
Skin
Speech/Language
Vision
Other (please indicate)
Remarks: (Please explain any abnormal findings.) _______________________________
_______________________________________________________________________
_______________________________________________________________________
4. RECORDS OF IMMUNIZATIONS (please indicate full dates)
DPT: BCG: Polio: MMR:
Hepa B: Measles: Others:
Others: (Please specify)
5. Is the child on medication?
No Yes, specify nature and duration:
Additional Comment: ______________________________________________________
________________________________________________________________________
Name of Medical Phone No.: Signature:
Practitioner:
Date: ____________________
FORM 3
CHILD NUTRITIONAL STATUS & SELF-HELP FORM
Instructions to Parents/Guardians: The following information is required for
your child attending the CDC for record purposes. Please complete this form by
providing information called for. For some of the items, the
Municipal/Rural/Barangay Health Unit Officer (M/R/BHUO), or Barangay
Nutrition Scholars (BNS) is required to provide the information. This is to be
given to the Child Development Teacher as of the child’s portfolio.
BASIC INFORMATION
Child’s
Name: Last First Middle
Birth Date: Se M F
x:
Address:
Parent/Guardian
Name(s)
Relations
hip:
Phone Work: Home:
Number(s):
Mobile
Number(s):
NUTRITION INFORMATION:
Results Date Taken
Test/Measurement
1st 2nd 1st 2nd
Height
Weight
Nutritional Status
Name M/R/BHU Phone No.: Signature:
Officer/BNS:
Date: ____________________
FEEDING/EATING:
1. Does your child have any food allergies we need to be aware of? __________
2. What food do you usually give to your child? __________________________
3. What is your child eating habbit? (i.e. bottles, finger foods, fruits, cereal,
etc.) _______________________________________________________
4. Is your child using a bottle? ________ If so, how often will s/he take for a
day? ________
5. What time does your child usually have: Breakfast ______ Lunch ______
Dinner _______
6. Is your child used to have a meal time snacks? Yes No
7. What food is normally eaten by your child?
Vegetable Rice Pork Cereals Noodles Fruit Juice
Chicken Soup Milk Meat Bread Fish Fruits
8. Does this child need any help in feeding himself/herself? Yes No
NAPPING/SLEEPING:
9. Does your child nap? Yes No
10. Does your child have a good sleep through the night? Yes No
11. What time does your child get up in the morning? _______________
12. Does this child have any special nap or bedtime routine? Yes No
BATHING/WASH-UP:
13. How do you bath/wash-up your child? _____________ How often? ________
14. Do you use baby soap? ____ Any soap? _____ Baby Shampoo? _________
15. Does your child have allergies in soap, shampoo, etc.? Please specify;
_____
16. Do you put baby oil after bath/wash-up? ______________ Powder? _______
TOILETING:
17. Is your child toilet trained? Yes No At what age? ____
18. Does your child doing any toileting? _______________ How often?
19. Does your child have a special word for urinating? ___ Bowel Movement: ___
20. Is your child using diaper? ___________ Cloth Disposable
21. How would you know if your child needs new diaper (S/He brings diaper to
you, cries, you have to check)? ____________________________________
22. How often do you change his/her diaper/baby clothes? __________________
I ATTEST THAT ALL INFORMATION PROVIDED ON THIS FORM IS TRUE AND
ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND IT
IS FOR CONFIDENTIAL USE IN MEETING MY CHILD’S HEALTH NEEDS IN NCDC.
Accomplished by : ______________________________ __________________
Signature over printed name of parent/guardian Date
Reviewed by: EMMA D. DIONEDA _____________________
Signature over printed name of CDW Date
FORM 4
CHILD OBSERVATION RECORD
Instructions: This form will serve as basis in determining the socio-emotional
development of the child.It must be accomplished fully by the Child
Development Teacher and kept in the portfolio of the child.
Child’s
Name
Sex: M F Ag Guardi
e an
Direction: Check (/) the behavior manifest by the child including the specific
comment.
BEHAVIOR COMMENT
st nd rd th
1 2 3 4 With With Done
Minimum Maximum Independentl
Assistanc Assistanc y
e e
Ask for help/assistance
Stands at the back and
observes other playing
Choose an activity
independently
Initiates play with other
child or invites another
child to play
Responds to another
child’s invitation to play
Joins a group that is
already playing
Plays with toys or
something alone
Plays in the dramatic
play area
Plays in the art area
Plays in another area
(indicate)
Plays blocks, and other
manipulative materials
independently
Solves his problem or find
a solution independently
Shows aggression or loss
of self-control.
Accomplished by : EMMA D. DIONEDA ________________
Signature over printed name of CDW
Date
FORM 5
PARENT INVOLVEMENT FORM
Instructions to the Parents/Guardians: Please check the boxes that
corresponds to the statement that you think you can do. This form will kept by
the Child Development Teacher for record purposes.
Parent/Guardian
Name(s)
Relationsh Phone Wor
ip: Number(s): k:
Home Mobile
: Number(s):
Child’s
Name:
Birth Se M F
Date: x:
Address:
PROGRAM SUPPORT
Assists in preparing instructional materials (e.i story/big books, poems,
rhymes, etc.
Assists in the classroom routine/activity time
Assists in the outdoor play
Acts as storyteller
Reads a book with children
Shares talent or knowledge (Pls. specify _________________)
Plays a musical instrument/ sing song with children
Leads a dance, song etc.
Assists in the preparation of meals for feeding
Assists during snack time
Helps maintain the cleanliness of the classroom
Assists in gardening at the school/with the children
Repairs/carpentry/paint
Shares discarded/recyclable resources for work
ADMINISTRATIVE SUPPORT
Assists in Family Support Program
Assists in planning/organizing Family Day
Prepares food for an event
Assists to solicit/donate
Assists in making signage’s/graphic design
Assists in organizing/emergency planning
Assists in fter-school program planning
Note any other ways you would like to get involved:
Accomplished by : ______________________________ __________________
Signature over printed name of parent/guardian Date
Reviewed by: EMMA D. DIONEDA __________________
Signature over printed name of CDW Date
