Presbyterian Early Learning Center
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Health History Form

Step 1 of 4

25%
  • Date Format: MM slash DD slash YYYY
  • Does child live with this parent? Yes/no
  • Does child live with this parent? Yes/no
  • Is/has child been under regular supervision of a physician? Yes/no
  • Date Format: MM slash DD slash YYYY

  • DEVELOPMENTAL HISTORY
    (For infants and preschool-age children only)
  • List any allergies the staff should be aware of.
  • What time does child get up?
  • What time does child go to bed?
  • Does child sleep well?
  • Is child toilet trained?
  • Does child have regular bowel movement?
  • Parent/Authorized Representative evaluuation of child's health
  • Is Child presently under a doctor's care?
  • If child takes prescription medications, what kind and any side effects:
  • What kind of special devices?
  • What kind of special devices?
  • Parent/authorized representative evaluation of child's personality
  • How does child get along with parent/authorized representative, brothers/sisters, and other children?
  • Has the child had group play experiences?
  • Does the child have any special problems/fears/needs? Explain.
  • What is the plan for care with the child is ill?
  • Reason for requesting day care placement.
  • Date Format: MM slash DD slash YYYY
  • If you would like a copy of this signed form emailed to you, please enter an email address. Leave blank if a copy is not wanted.
  • This field is for validation purposes and should be left unchanged.
Sunnyvale Preschool

Preschool Programs

  • Part-time Preschool 2’s
  • Part-time Preschool 3’s
  • Part-time PreK
  • Full-time Preschool 3’s (Daycare)
  • Full-time PreK (Daycare)
  • Infant/Toddler Program
  • Young 2’s Program
PELC (Presbyterian Early Learning Center)
728 W. Fremont Ave, Sunnyvale, CA 94087 · 408-245-2253 · Contact us
PELC is an outreach of the Sunnyvale Presbyterian Church
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