Weekly cohort Enrollment Questionnaire 2025-2027 Child's Name * First Name Last Name Child's Date of Birth * MM DD YYYY City & State of Child's Birth * Primary Language(s) Spoken to the Child * Child's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Caregiver 1 Information Parent/Caregiver 1 Name * First Name Last Name Parent/Caregiver 1 Phone * (###) ### #### Parent/Caregiver 1 Email * Parent/Caregiver 1 Employer Parent/Caregiver 2 Information Parent/Caregiver 2 Name First Name Last Name Parent/Caregiver 2 Phone (###) ### #### Parent/Caregiver 2 Email Parent/Caregiver 2 Employer Alternate & Emergency Contact(s) Please provide the name, phone number, address, and relationship to the child of the primary emergency contact(s) to be contacted in the event that no primary parent/caregiver can be reached. * You may provide up to four names. Yalla recommends listing at least two. Child's Health Report Please provide the name, phone number, and address of your child's pediatrician. * Does your child have any allergies? * Does your child have any food intolerances? * Does your child have any environmental allergies or intolerances? Does your child take any medications regularly? If so, will Yalla Childcare ever be required to administer these medications? * Does your child have any medical conditions or special needs? * Is your child up-to-date with their immunizations in accordance with recommendations made by the Centers for Disease Control and Prevention (CDC)? * Yes No I don't know Sleep Plan At Home, My Child Sleeps in: * Bassinet/Cosleeps Crib Bed Floor Cot Please describe, in as much detail as possible, your child's daytime napping routine. Please include the average length of your child's nap(s) during the day and the average time(s) of day that the nap(s) occur. * Please describe, in as much detail as possible, what your child needs when going to sleep? (i.e. to be rocked, to be sung to, to be fed a bottle right beforehand, to be placed in a sleep sack, given a pacifier, etc.) Providing a clear order of events is VERY helpful to your child's Yalla caregivers. * Feeding Plan Does your child eat solids? If so, describe what they eat, their level of confidence, and any other important details we should know about feeding your child. * Diapering/Toileting Routine Please describe your child's diaper/toileting routine. Additional Information What experience has your child had thus far with other childcare providers outside of care provided by their immediate parents/caregivers? * Describe your child. What is their disposition? What makes them upset? What soothes them? What excites or interests them? Thank you!
