Republic of the Philippines

BARANGAY BUAYA
Buaya, Lapu-Lapu City

BUAYA CHILD DEVELOPMENT CENTER III

REGISTRATION FORMS OF DAY CARE CHILDREN

Name of Child
Date of Birth Age Sex
Name of Mother Birthday
Educational Attainment Occupation
Name of Father Birthday
Educational Attainment Occupation
Number of Sibling/s Religion Birth Order
Address Contact Number

Family Composition Birthday Age Sex

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Filled up by:
Relation to the Child
Signature Over Printed Name Date

Checked by:

JOSEPH C. IGOT
Day Care Worker
 Sociodemographic Profile

Indicate the complete sociodemographic profile of the child.

Child’s Name Sex Date of Birth

month day year
Address
Barangay Municipality/City Province Region

Child’s Handedness (Check appropriate box) Right Left

Both Not yet established

Is the child presently studying? (Check appropriate box) Yes No

If yes, write name of child’s school/learning center/day care:
Father’s Name: Father’s Age:
Father’s Occupation: Father’s Educational Attainment:
Mother’s Name: Mother’s Age:
Mother’s Occupation: Mother’s Educational Attainment:
Child’s Number of Siblings Child’s Birth Order (1st, 2nd, 3rd, etc.)

Child’s background (ex: behavior/health/etc.)

Family environment (ex: Health of a family members/family problems/economic condition/etc.)

Parent’s stimulating activities for the child (What are the activities/things that the parents do to
help stimulate the child’s development?

Home environment (ex: Facility/type of house/household items/interaction/etc.)

 Republic of the Philippines
BARANGAY BUAYA
City Social Welfare & Development Office
Lapu-Lapu City

BUAYA CHILD DEVELOPMENT CENTER III

We/I and
(Father/Guardian) (Mother/Guardian)
of legal ages, resident of
, is/are the parent/s/ guardians of the minor,

The said minor, was born on

at

The minor is found to be eligible for Day Care Service and referred to:

BUAYA DAYCARE CENTER III by JOSEPH C.IGOT

(Name of Day Care Center) (Name of Day Care Worker)
for the period of SY 2023-2024 (School Year)

That we consent to the provision of said service to our child for the stated period
herein:
That will provide support in the different activities and continue such activities at
home in order to attain the objectives of the Day Care Service for the welfare of our
child;
That we will report any difficulties/problem to the Social Worker/Day Care Worker
and cooperate with them to solve the said problem;
That this consent was explained to us and we fully understand its implication.

Issued on at
(date) (place)

(Signature of Father) (Signature of Mother)

Witness:

JOSEPH C. IGOT
Social Worker Day Care Worker
 Republic of the Philippines
BARANGAY BUAYA
Buaya, Lapu-Lapu City

BUAYA CHILD DEVELOPMENT CENTER III

INTAKE FORM FOR DAY CARE SERVICE

(To be used by Social Worker for Children needing Day Care Service)

PROBLEM PRESENTED (Check one or more circumstances presented.)

Mother is working outside from home; no responsible adult can take care of the child.

Mother have a baby to take care of and cannot attend the needs of the child’s day care

service.
Mother is fully occupied with household chores and cannot attend to provide child
development activities.
Mother tends to exploit child, e.g., using child begging.
Mother tends maltreat child.

1.) Name of Child 2.) Age 3.) Sex

4.) Height 5.) Birth Date 6.) Birth Place

7.) Religion 8.) Address

9.) Family composition (include all family members who lived in the house)

Name in Birth Order Age Sex Civil Relation to Highest Time Presented at Occupation Income Health Attitude
(Include Client) Status Child Education Home Condition Toward
Child

10.) Development information (Based on Child Development Checklist. Check if child’s achievement on admission for Day Care Center Service corresponds to 50% and
above of indicators for his/her age).
Cognitive/adaptive skills Social values in relation to self

Language competency Social values in relation to family

Personal behavior Social values in relation to non-relative

Social values in relation to country/community

11.) Weight 12.) Height 13.) Nutritional Level 14.) Physical Handicap/Impairment

15. Home Condition

k. Home condition that are observed as likely detrimental to the child?

l. Conditions in the neighborhood that are detrimental to the child

m. Distance of home to day care center Transportation facility to day care center

n. Name of escort for the child Relationship to the child

o. Adult who will receive child on return from day care center

16.) Parental Expectations

p. What do parents expect the child to learn from attendance at the day care center?

q. What do parents expect to teach their own child at home?

r. What do parents perceive as their role in relation to the day care center?

s. What do parents expect of the social workers?

t. What do they perceive as their other responsibilities in relation to the

success of the day care program?

u. What do parents expect of the parents of their children at the day care center?

17.) Other Impressions

18.) Assessment of eligibility of child for day care service

19.) Recommended period of day care service (time and month of day care service)

Confirmed by: Accomplished by:

JOSEPH C. IGOT

Day Care Worker Social Worker Officer