Republic of the Philippines

DEPARTMENT OF SOCIAL WELFARE & DEVELOPMENT

Region X Field Office No. ____________
Province of Misamis Oriental
Municipality of Villanueva
Barangay ________________________
___________________________________
Name of Child Daevelopment Center

INTAKE FORM FOR DAY CARE SERVICE

I.PERSONAL DATA
Name of Child ___________________________________________________ Age ______________ Sex _____________
Date of Birth ____________________ Place of Birth ____________________________ Religion ____________________
Address ___________________________________________________________________________________________
Nutritional Status _______________________ Weight _______________________ Height ________________________
Physical disability, if any: _____________________________________________________________________________

II.FAMILY COMPOSITION
Family composition (Include parents and all members of the family who live as one in the household. i.e. share dwelling, same source of income and the same
kitchen).
Relation Time Attitude
Name/By Birth order Highest Health
Age Sex Civil Status to Present at Occupation Income toward
(include child) Education Condition
Child Home child

III.DEVELOPMENTAL INFORMATION
1.Birth Certificate: available ____________________ not available _____________________
2. Child Development Checklist __________________________________________________
Check if child’s achievement on admission for day care service corresponds to 50% and above, of indicators for his age, using the child development checklist.

_____ a.motor development _____ f.social values in relation to self

_____ b.personal – social development _____ g.social values in relation to family
_____ c.cognitive adaptive development _____ h.social values in relation to non – relatives
_____ d.language competency _____ i.social values in relation to country/community
_____ e.social values in relation to God

IV.HOME CONDITIONS
1.Home conditions that are observed as likely detrimental to the child (e.g. mother working part of the day but leaves no adequate adult supervision to child.)
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

2.Conditions in the neighborhood that are detrimental to the child (e.g. presence of gambling places, near street, etc.)
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

3.Distance of home to day care center ___________________________________________________________________________________________________

Transportation facility to day care center ________________________________________________________________________________________________

4.Name of escort for child _____________________________________________________________________________________________________________

Relationship to child ________________________________________________________________________________________________________________

5.Adult who will receive child on return from day care center _________________________________________________________________________________
Relation to child ____________________________________________________________________________________________________________________

V.PARENTAL EXPECTATIONS
1.What do parents expect to learn from attendance at the day care center?
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

2.What are the parents’ perceived role in inculcating values to the child at home?
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

3.What do the parents perceive as their role in relation to the Day Care Worker?
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
4.What do they expect of the social worker?
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

5.What do the parents perceive as their role in contributing to the success of the Day Care Center?
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

6.What do the parents expect to their children at the day care center?
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

7.Other expectations
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

VI.EVALUATION AND RECOMMENDATION

1.Assessment of eligibility of child for day care service:
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

2.Recommended period of day care service (time and months of day care service)
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

Reviewed by: Accomplished by:

LIUXENE E. ORDITOR _________________________

MSWDO Child Development Worker

___________________
Date