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Intake-Form-NCDC

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SHERWIN JOY DE LA CRUZ
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10 views

Intake-Form-NCDC

Uploaded by

SHERWIN JOY DE LA CRUZ
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CONSENT FOR PROVISION OF DAY CARE SERVICE

Witness:
We/I ________________________ and _______________________
(father/guardian) (mother/guardian) VERONICA B. SALMON ANTONIA C. AGNGARAYNGAY
Republic of the Philippines
of legal age/s resident of Brgy. #40 BUYON, Bacarra Ilocos Norte are/is the MSWDO
MUNICIPAL SOCIAL WELFARE AND DEVELOPMENT DCW
OFFICE
parent[s]/guardians of the minor, ________________________________ Bacarra, Ilocos Norte

The said minor, _____________________ was born on INTAKE FORM FOR DAY CARE CENTER
___________ at
__________________________________________________. I. PERSONAL DATA

The minor is found to be eligible for Day Care Service and referred Name of Child: ___________________________________________
to BUYOB CHILD DEVELOPMENT CENTER by VERONICA B. Date/Place of Birth: _______________________________________
SALMON____ Address: Brgy. #40 Buyon, Bacarra, Ilocos Norte_______________
[Name of Day Care Center] [Name of MSWDO] Age: ______ Sex: _________ Religion: ______________________
For the period of __________________________________________. Nutritional Status: ________ Weight: _______ Height: _________
Physical Handicap/impartment, it any: ________________________
That we consent to provision of said service to our child for the
stated period herein; II. FAMILY COMPOSITION:
Family composition [include parents and all members of the
That will provide support in the different activities and continue family who lives as one household, i,e, share dwelling, same source of
such activities at home in order to attain the objectives of the Day Care income and the same kitchen].
Service for the welfare of our children.
Highest Educ.
Rel. to Child
Civil Status
Time Present
Name by
Age IncomeOccupation Attitude
That we will report any difficulties/problems to the MSWDO/Day Birth Order Sex at home
Health
toward Child
Care Worker and Worker and cooperate with them to solve said problems; [include
Client]
That this consent was explained to us and fully understand its
implications.

Issued on ____ , 2023 at Brgy. 40 Buyon, Bacarra, Ilocos


Norte_
[Date] [Place]

_____________________________ _____________________________
Signature of Father Signature of Mother
Relation to child
_______________________________________________

III. DEVELOPMENT INFORMATION:


V. PARENTAL EXPECTATIONS:
1. Birth Certificate [ ] available [ ] not available
1. What do parents expect to learn attendance at day care center?
Check if child’s achievement on admission for Day Care Service
______________________________________________________________
corresponds to 50% and above of indicators for its age, using Child
______________________________________________________________
development checklist.
2. What are the parents’ perceived role in inculcating values to the child at
[ ] a. Motor Development [ ] f. Social Values in relation to self
home?
[ ] b. Personal-Social Development [ ] g. Social Values in relation to family ______________________________________________________________
[ ] c. Cognitive Adaptive Development [ ] h. Social Values in relation to no-relatives ______________________________________________________________
3. What do parents perceive as their role to the Day Care Worker?
[ ] d. Language Competency [ ] i. Social Values in relation to
______________________________________________________________
country ______________________________________________________________
[ ] e. Social Values in relation to God [ ] /community 4. What do they expect at the MSWDO?
______________________________________________________________
IV. HOME CONDITIONS: ______________________________________________________________
1. Home conditions that are observed as likely detrimental to the child [e.g. 5. What do the parents perceive as their role in contributing to the success
of the Day Care Center?
mother working apart of the day but leaves no adequate adults supervision
______________________________________________________________
to child] ______________________________________________________________
______________________________________________________________ 6. What do the parents expect of their children at the Day Care Center?
______________________________________________________________
2. Condition in the neighborhood that are detrimental to the child [e.g.
______________________________________________________________
presence of gambling places, near street, etc.] 7. Other expectations
______________________________________________________________ ______________________________________________________________
3. Distance of home to day care center ______________________________________________________________
_______________________________ VI. EVALUATION AND RECOMMENDATION:
Transportation facility to day care center 1. Assessment of eligibility of child for day care service:
___________________________ ______________________________________________________________
4. Name of escort for child ________________________________________ ______________________________________________________________
Relation to child ______________________________________________ 2. Recommendation period of day care service [time and months of day care
5. Adult who will receive child on return from day care center service]
____________
______________________________________________________________
______________________________________________________________

Referred to: Accomplished by:

BUYON CHILD DEVELOPMENT CENTER VERONICA B. SALMON


Day Care Center MSWDO

Date

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