CONSENT FOR PROVISION OF DAY CARE SERVICE

We,/______________________________and___________________________
(Father/Guardian) (Mother/Guardian)

of legal age/s, resident of _________________________________________________

_________________________ are/is the parent/s guardian of the minor,
_________________________________________.

The said minor,_________________________________ was born on ____________

__________________________ at __________________________________,
That minor is found eligible for Day Care Services and referred to
_________________________________ by _______________________________
(Child Development Center) (Child Development Worker)

That we consent the provision of said service to our child for the stated period herein;
That we will provide in the different activities and continue such activities at home in
order to attain the objectives of the Day Care Services for the welfare of our child;

That we will report was explained to us and we fully understand its implications.

Issued on _____________________at ______________________________________

(Date) (Place)

_______________________________ _______________________________
Signature of Father Signature of Mother

WITNESSES:

MA. CELERINA P. AGCAMARAN, RSW ________________________________

City Social Welfare and Development Officer Child Development Worker
 AGREEMENT LETTER

I/We ____________________________________________________________

the parents/guardian of ____________________________________________ who is

currently enrolled at _____________________ Child Development Center have agreed

to submit his/her Birth Certificate and Health Record on or before the evaluation Date

Started on the ECCD Checklist (Early Childhood Care and Development) as one of the

requirement upon admission to Day Care Service conducted by City Social Welfare and

Development Office, ___________________________________________

(Address)

__________________________ __________________________
Parent/Guardian CDW

__________________________
Date
 INTAKE FORM FOR DAY CARE SERVICES

I. PERSONAL DATA

Child’s Name: _________________________________________________________

Age:_________________ Sex:______________ Religion:___________________
Date of Birth: ____________________ Place of Birth:__________________________
Address:______________________________________________________________
_____________________________________________________________________
Height:____________________ Weight/NS:_________________________________

Physical Disability, if any (specify):__________________________________________

Health Record: Allergies___________________ Chronic Condition:____________
Are you a 4Ps Recipient? Yes______ No______
Child’s Handedness
[ ] Right [ ] Left [ ] both [ ] not yet establish

Father’s Name: ______________________________________________________

II. FAMILY COMPOSITION

Name By Birth A S Relation Time Attitude

Civil Educ’l Health
Order G E to Present Occupation Income Toward
Status Attain’t Condition
(Include child) E X Child at Home Child

III. DEVELOPMENT INFORMATION

1. Birth Certificate: available ________________ not available_________________
2. Marriage Contract: Date of Marriage ____________________ Registry No.__________
3. Child Development Checklist _______________________________________________

Check if Child’s achievement on admission for day care service corresponds to 50% and above,
of indicator of his age, using the child development checklist.

__________a. gross motor domain __________f. expressive language domain

__________b. fine motor domain __________g. cognitive domain
__________c. self-help domain __________h. social emotional domain
__________d. receptive language domain
IV. Home Condition
1. Home conditions that are observed are likely detrimental to the child (e.g. Mother
working part of the day but leaves no adequate adult supervision to child.)

2. Condition in the neighborhood those are detrimental to the child) e.g. presence of
gambling places, near streets, etc.)

3. Distance of Home to Child Development Center __________________________

Transportation facility to Child Development Center _______________________
4. Name of escort for child_____________________________________________
5. Adult who will receive child on return from Child Development Center_________

V. Parent Expectation
1. What do parents expect to learn from attendance at the Child Development Center?

2. What are the parent’s perceived in calculating values to the child at home?

3. What do the parent’s roles to maintain good relationships with the Child
Development Worker?

4. What do they expect from the social worker? ____________________________

5. What are the parent’s perceived roles on contributing to the success of the CD
Service Program?__________________________________________________
________________________________________________________________
6. What do parents expect of their children at the Child Development Center?
________________________________________________________________
7. Other Expectation _________________________________________________
________________________________________________________________

VI. Evaluation and Recommendation

1. Assessment of eligibility of the child for child development service:___________
________________________________________________________________
2. Recommended period of the child development service (time and months of child
development service) ______________________________________________

Accomplished by:

_____________________________
Child Development Worker
Reviewed by:

_________________________ _________________________
Monitoring Staff Date
___________________________ CHILD DEVELOPMENT CENTER

INDIVIDUAL PARENT’S CONERENCES

Date Highlight Suggestion/Recommendation

 OBSERVATION RECORD

Date Observation Discussion

 ___________________________ CHILD DEVELOPMENT CENTER

HOME VISIT REPORT

Name of Child:__________________________________________________________
Address:_______________________________________________________________
Date of Home Visit: ______________________________________________________
Reason of Home Visit: ____________________________________________________
Action Taken:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Follow up:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

_____________________ _____________________
Signature of Parent CDW

HOME VISIT REPORT

Name of Child:__________________________________________________________
Address:_______________________________________________________________
Date of Home Visit: ______________________________________________________
Reason of Home Visit: ____________________________________________________
Action Taken:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Follow up:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

_____________________ _____________________

Signature of Parent CDW

 INITIAL AND ANNUAL HEALTH RECORD
(For use of Physician)
I. MATERNAL HISTORY PLEASE CHECK ILLNESSESS DURING PREGNANCY:
________Goiter ________German Measles ________Heart Dis ease
________Diabetes ________Hepatitis ________Others (Please specify)

II. BRIEF HISTORY:

a. Type of Delivery b. Place of Delivery
________ Normal ________ Hospital
________ Caesarian Section ________ Home
________ Forceps ________ Others (Please specify)
b. State Complications if any_________________________________________
_________________________________________
c. Allergies if any __________________________________________________
__________________________________________________
III. IIMUNIZATION: Date Given
DPT _____________________ _____________________
POLIO _____________________ _____________________
BCG _____________________ _____________________
MEASLES _____________________ _____________________
TETANUS _____________________ _____________________
HEPATITIS B _____________________ _____________________
IV. DEWORMING Date of last Deworming
______ Yes _____________________ _____________________
______ No _____________________ _____________________
V. DISABILITY/IMPAIRMENTS(Please Check if any)
______ Congenital Deformities ______ Speech defect
______ Deafness ______ Emotional Disturbance
______ Other (Specify) ________
VI. PREVIOUS ILLNESS: Dates
________________________ _____________________
________________________ _____________________
VII. CURRENT HEALTH STATUS:
______________________________________________________________
______________________________________________________________
VIII. PERTINENT PHYSICAL EXAMINATION
HEENT ________________________________________________________
ABDOMEN _____________________________________________________
GUT __________________________________________________________
MASCULA _____________________________________________________
NEURO _______________________________________________________
IX. REMARKS
______________________________________________________________
______________________________________________________________
____________________________ __________________
Signature of Physician Date

____________________________ __________________
Signature of Dental Officer Date
 ANNECDOTAL RECORD

 Child Observed:____________________________________________________
 Observation Setting:_________________________________________________
 Observer:_________________________________________________________
 Date:_____________________

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