SUNSHINE CHILD DEVELOPMENT CENTER

Kaytitinga II, Alfonso Cavite

FORM 1 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 number: Home: Work:
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: LIEZL I. ROTAIRO

Signature over printed name of Date
CDW
Registration Form Page 2

4p’s yes __ no__ I.D. number :________________

PWD I.D number: (if applicable)_____________________

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
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):

Accomplished by: ______________________________________ __________________

Signature over printed name of parent/guardian

Date

Reviewed by: LIEZL I. ROTAIRO __________________

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.) and
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? (ex: 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 she/he is in the Center? (ex. 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 Limit) (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? (e. g. 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 snack? 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 do 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: LIEZL I. ROTAIRO _____________________

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: LIEZL I. ROTAIRO

________________
Signature over printed name of CDT
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)
Relationshi Phone Wor
p: Number(s): k:
Home: Mobile
Number(s):
Child’s Name:
Birth Date: Se M F
x:
Address:
PROGRAM SUPPORT

Assists in preparing instructional materials (e. g. 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 after-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: LIEZL I. ROTAIRO __________________

Signature over printed name of CDW
Date

REPUBLIKA NG PILIPINAS
TANGGAPAN NG KAGALINGAN PANLIPUNAN AT PAGPAPAUNLAD
REHIYON IV –A CALABARZON
BAYAN NG ALFONSO CAVITE
INTAKE FORM FOR DAYCARE SERVICE
 PANSARILING TALA:
PANGALAN NG BATA: EDAD: KASARIAN:
PETSA AT LUGAR NG KAPANGANAKAN: RELIHIYON:
TIRAHAN:
KALAGAYANG PANGKALUSUGAN: TIMBANG : TAAS :
KAPANSANAN (KUNG MERON):
I. BUMUBUO NG PAMILYA:
PANGALAN EDAD KASARIA KALAG RELASYO PINAG- ORAS NA TRABAH KINIKI KALUSUGA PAKIKITUNGO
N A N SA ARALA NASA O TA N SA BATA
YANG BATA N TAHANA
SIBIL N

KALAGAYANG PANTAHANAN
1.Isulat ang kalagayang pantahanan ayon sa pangangailangan niya:Halimbawa ina ay naghahanap-buhay at
walang maiiwanan sa mga bata.

2.Ang kalagayang pangkapaligiran na hindi maganda sa mga bata tulad ng mga pasugalan o ang tahanan ay
malapit sa kalye.

3.Ang layo ng bahay sa Day Care Center ( NAGSASAKAY BA O NILALAKAD )

Uri ng sasakyan patungo sa Day Care Center
4.Pangalan ng maghahatid o susundo sa bata:
Relasyon sa bata:
5.Sino ang tatanggap o madadatnan ng mga bata pagkagaling sa Day Care Center?

Relasyon sa bata:
V. INAASAHAN NG MGA MAGULANG:
1.Anu-ano ang mga inaasahang matutunan ng bata sa Day Care Center?

2.Ano ang tungkulin ng mga magulang upang mahubog ang magandang ugali ng mga bata?

3.Ano ang inaasahan ng mga magulang na tungkulin ng Child Development Worker?

4.Ano ang kanilang inaasahan sa SOCIAL WORKER?

5.Ano ang inaasahan ng mga magulang sa pagpapaunlad ng CHILD DEVELOPMENT CENTER?

6.Ano ang inaasahan ng mga magulang sa kanilang anak habang nasa Day Care Center?

7.Iba pang inaasahan:

Pagsisiyasat at Mungkahi
1.Pagtasa ng kakayahan ng bata na makisama sa Day Care Service:
2.Maipapayong tagal na panahon ng pagtigil ng bata sa Day Care Center (oras,araw at buwan ng DAY
CARE SERVICE ).

Isinangguni kay: Isinagawa ni:

Child Development Worker Social Worker

Child Development Center Petsa

REPUBLIKA NG PILIPINAS
TANGGAPAN NG KAGALINGAN PANLIPUNAN AT PAGPAPAUNLAD
REHIYON IV,BAYAN NG ALFONSO,CAVITE
PAHINTULOT PARA MABIGYAN NG PANGANGALAGANG PAMBATA
Kami/Ako at
 (AMA/TAGA-PANGALAGA) ( INA/TAGA-PANGALAGA)
may sapat na gulang,nakatira sa at may
magulang/taga-pangalaga ng bata si
Na,ang nasabing bata ay ipinanganak noong
ika sa
Na ang batang ito ay nararapat na maalagaan sa DAY CARE CENTER ng
Sa pamamagitan ni
Mula sa hanggang
Na,kami ay tutulong sa pagsasagawa ng ibat ibang Gawain at pagpapatuloy sa aming tahanan
upang makamit ang layunin ng programa para sa kanyng kapakanan.
Na.kami ay mag-uulat sa SOCIAL WORKER ukol sa kahinaan at makipagtulungan sa kanila
upang sakaling matulungan siya.
Na,ang pahintulot na ito ay maipaliwanag ng maayos sa amin at maunawaan mabuti ang
kahulugan.
Ibinigay ngayon sa

Lagda ng Ama Lagda ng Ina

Mga Saksi:

CHILD DEVELOPMENT WORKER SOCIAL WORKER