Enroll

All families will be interviewed for child placement after enrolling.
One week free trial.
We are accepting vouchers (HRA, ACS)
Private Tuition – Reasonable Rates!!
Center is open 8:00 Am – 5:30pm,
extended hours 6am-8:00am 5:30pm-6pm
AND
NOW 7pm-midnight

Referred By
How did you hear about the school?
Program Selection*
- Pre-School - Private - Ages 2-5
- After School - Up to age 6
- DOE 3k
- DOE 4k
- Infants and 1 Year Olds
Child's Information
Child's Name*
First Last
Nickname
Gender*
Date of Birth*
Child's Age*
Please enter a number greater than or equal to 1.
Enrollment Date
SSN*
Primary Home Address*
Street Address City ZIP Code
Home Phone*
Child's Primary Residence*
- Mother
- Father
- Both
- Guardian
Child's Race (Check all that apply)
- American-Indian or Alaskan Native
- Asian
- Black or African-American
- Native Hawaiian / Other Pacific Islander
- White
- Multi or Bi-racial
- Other
- Unspecified
Hispanic
- Yes
- No
Primary Language
Primary Language Proficiency
- Little
- Moderate
- Proficient
Secondary Language
Secondary Language Proficiency
- Little
- Moderate
- Proficient
Enrolled Days
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Only Applicable to Centers Offering Part-Time Seats
Parent/Guardian Information
Mother/Guardian Name*
First Last
Mother/Guardian Email*
Mother/Guardian Cell Phone*
I hereby permit Young Minds in Motion to text message my cell phone number only when important announcements must be communicated, such as emergencies, school closing, and other events that will affect my child's care. (Please Initial)*
Mother/Guardian Home Phone
Mother/Guardian Work Phone
Mother/Guardian Place of Employment
Mother's Date of Birth*
MM slash DD slash YYYY
Parent/Guardian Marital Status*
- Single
- Married
- Separated
- Divorced
- Widowed
Father's Name
First Last
Father's Email
Father's Cell Phone
I hereby permit Young Minds in Motion to text message my cell phone number only when important announcements must be communicated, such as emergencies, school closing, and other events that will affect my child's care. (Please Initial)
Father's Home Phone
Father's Work Phone
Father's Place of Employment
Father's Date of Birth
MM slash DD slash YYYY
Parent/Guardian Marital Status
- Single
- Married
- Separated
- Divorced
- Widowed
Comments
Payment Option*
- Private Pay
- ACS Voucher
- HRA Voucher
- DOE
Consent*
I acknowledge and agree to COVID policy.
Medical Consent release

Young Minds in motion will contact your child’s Pediatrician for their medical records. Please provide:
Doctor's Name
Doctor's Number
Doctor's Email Address
Consent
I give Young Minds in Motion permission to obtain my child’s medical records for the purpose of enrolling them into school.
Print
Date
MM slash DD slash YYYY
Young Minds in Motion Disciplinary Procedures & Policies

A very important part of the preschool experience is helping children learn how to get along in the world, enjoy being with other children, and follow the direction of an adult other than their parent. A caring and positive approach will be taken regarding behavior management and discipline. The teachers will focus on the positive behaviors of the children and reinforce those behaviors as often as possible. Our goal is to help the children develop self-control and responsibility for their actions.
1. Encouraging children to use their words when having a disagreement with another child facilitating children in their attempts to settle their own disputes.
2. Redirecting behavior when this seems potentially effective.
3. Separating a child from the group (Time-Out) – one minute away for each year of age.
4. Counseling children individually about their behaviors.
5. Making parents aware of disciplinary concerns (Incident Report).
Disruptive Behavior distracts from the full benefit of the preschool program and will result in consequences. The following behaviors are considered disruptive:
• Requires constant attention from the staff
• Inflicts physical or emotional harm on other children, adults, or self
• Disrespects people and materials provided in the program
• Consistently disobeys the rules of the classroom
• Verbally threatens other students and/or staff
• Uses verbal or physical activity that diverts attention away from the group of children.
Discipline Procedures for disruptive behavior

Level 1: Student and teacher discussion, and teacher’s procedure of notification to parent through Kinderlime and phone contact. Teacher discusses behavior with the student and student receives an infraction(s) based on their choice(s). Time outs and sitting out an activity.

Level 2: Student and teacher discussion, student may possibly receive time to think about their choices, as well as teacher’s procedure of notification to parent through the class behavioral management program.

Level 3: Once a child has served 3 time outs, or 3 parent notifications for behavior, a parent/teacher conference will be arranged to discuss positive solutions.

Level 4: Parent meeting with administration.

Level 5: Suspension –Depending on the infraction (one day up to 5 days).

Level 6: Dismissal -When little or no change is evident, and school personnel have exhausted all available means to affect change, and/or the welfare of the other students is endangered, the student will be expelled. This decision rests with the school administration.

Children cannot become self-disciplined unless adults teach them right from wrong. At Young Minds in Motion, children will be taught the expectations for correct behavior and encouraged to live and act accordingly. When children know something is wrong, and choose to do it anyway, consequences will follow to communicate that the behavior is not acceptable and will not be tolerated in our school.
Discipline Policy Agreement*
I have read Young Minds in Motion Disciplinary Policies and Procedures. I have discussed this with my child and agree to comply with the discipline policies and procedures of Young Minds in Motion
Biting Policy

Although it is not uncommon for very young children to bite, it is a behavior that is taken very seriously, and is strongly discouraged. When children are older than 24 months, biting is less common. Language is beginning to become the tool of choice, with “No!” and “Mine!” is used most frequently. These verbal warnings alert the teachers that it may be time to intervene, and redirect the playmates involved in another direction. When an older child bites, the preschool’s policy is:
- 1st offense the child who bites will quickly be placed in “Time Out”, while the teacher comforts the child who has been bitten, and attends to cleaning the bite. Then, the teacher will return to “Time Out” and speak with the offending child about what has happened. The child is reminded that teeth are for eating food & smiling, not for biting. Both sets of parents will be told of the incident. The parent of the child that bit the other student will be asked to come and pick up the child for early dismissal.
- 2nd offenseThe child’s parents will be asked to keep their child at home for 2 days and focus on helping the child understand that biting is unacceptable
- 3rd offense removal from the program for the remainder of the school year.
Consent*
I have read Young Minds Biting Policies. I have discussed this with my child and agree to comply with the biting policies and procedures of Young Minds in Motion
Transportation Agreement
I give permission for Young Minds in Motion, or any approved employee of Young Minds in Motion, to transport my child via company vehicle for the following reasons (select all that apply):
Field Trips*
Morning Pick-up Service*
Evening Drop-off Service*
Excursions to the park*
Emergency Purposes*
Any*
1. The caregiver will never leave my child(ren) unattended in any motor vehicle or other form of transportation.
2. Each child will board or leave a vehicle from the curbside of the street.
3. My child(ren) will be secured in safety seats or by safety belts as appropriate for the age of the child(ren) in accordance with the law.
4. Any motor vehicle used to transport my child(ren) will have current registration and inspection stickers, and must be operated by a person who is at least 18 years of age and possesses a valid driver’s license.
5. The caregiver will notify me in advance of any instance where my child(ren) will be transported while in care.
This form is to authorize my child’s participation in all field trips organized and conducted by Young Minds in Motion.

This form is also a statement of release of liability as detailed below.

Note: Information will be sent home prior to each field trip detailing where the field trip will take place. You, the parent/guardian, will be allowed to disallow your child’s participation in any outing should you choose to do so.

The undersigned Parent/Guardian (hereinafter, “I”) understands that the students will be chaperoned/supervised while en route, participating and during schedule time, and that normal precautions will be taken in their interest for safety and well-being.

I hereby agree to release Young Minds in Motion and its trustees, employees, volunteers and sponsors (collectively, the “Indemnities”) and to indemnify and hold the indemnities harmless form all actions, claims, liability, and expenses, whether known or unknown, present or future (and expressly including (1) actions brought or claims made by the student named above after reaching the age of majority, and (2) actions or claims for damages caused in whole or in part by the negligence or gross negligence of the indemnities) relating to or arising from or connected in any manner with the student’s participation in the field trip identified herein.

In case of emergency, I give my approval and authorization for first-aid treatment and any medical treatment by local physicians and/or hospital including surgical procedures. I agree to accept responsibility for payment of all charges incurred during this medical treatment.

This form must be signed and returned to the owner, director or administrator in charge of this group on the day of departure. No student will be permitted to go on the field trip that has not completed this form and returned it to the proper school personnel.
I hereby give consent to my child the use of all the equipment of the Playground on-site and/or off-site of Young Minds in Motion. Equipment of the playground includes swing sets, all climbing structure, slides, bikes, scooters. I recognize that injuries may occur. I fully understand that the members of Young Minds in Motion are not physicians or medical practitioners of any kind. With the above in mind, I hereby allow Young Minds in Motion staff members to give first aid to my child or children in the event of any injury or illness, and if deemed necessary by the Daycare to call 911 to seek medical help, including transportation to any healthcare facility or hospital.

I understand that it is the express intent of Young Minds in Motion to provide for the safety and protection of my child and, in consideration for allowing my child to play at the playground, I hereby release Young Minds in Motion and its employees from all liability for any and all damages and injuries suffered by my child while playing at the playground. I also affirm that I now have and will continue to provide proper hospitalization, health and accident insurance coverage, which I consider adequate for my child protection and my own protection. I also understand that my child will be with supervision at all times they are playing at the park. This acknowledgment of risk and waiver of liability, having been read thoroughly and understood completely, is signed voluntarily as to its content and intent.
Tuition Agreement Form
Tuition Agreement*
- Private: I understand that my child’s tuition is an ongoing monthly fee and I am responsible for my child’s tuition amount based on his/her scheduled days, regardless of any days my child is ill, on vacation, or does not attend for any other reason. Deposits will be accepted on a case-by-case basis. Deposits are non-refundable.
- ACS: I understand that my child’s co-pay is an ongoing weekly fee and I am responsible for my child’s co-payment based on the ACS form. I am responsible for my child’s weekly co-pay fee even if my child does NOT attend for the week or is absent for 1 or more days during the week.
- HRA: I understand that my child’s co-pay is an ongoing weekly fee and I am responsible for my child’s co-payment based on the HRA form. If my child attends for one day out of the week I am still responsible to pay the weekly fee.
Payment Schedules

You will be billed on Fridays for payments due that Sunday which is for services for the following week. If no payment is made by Monday night, and no arrangements have been made, there will be no service until payment is made. Although your child is not allowed to attend while tuition is unpaid, you are still responsible for payment for the time they are not there. A bill will be sent to you via email and must be paid ONLY via the Procare app.
Payment Schedules
- Private: Late payments and Non-Payments: I understand that payments made after the tenth of the day of the month are considered late and a late fee of $35 will be assessed. I am aware that if the 10th day of the month falls on a weekend/holiday the last day tuition can be paid without a late fee is the last day the center is open before the holiday/weekend.
- ACS & HRA: Late payments and Non-Payments: I understand that payments made after the Monday after the previous Friday of the week are considered late and a late fee of $5/day will be assessed. I am aware that if the Friday/Monday of the week falls on a weekend/holiday, the last day that tuition can be paid without a late fee is the day prior to when the center is open before the weekend/ holiday.
Delinquent Accounts: I understand that if accounts continue to be delinquent, the center has the right to discontinue services.

Returned Checks: I understand that if my tuition check is returned for any reason, I will be charged a processing fee of $25.00. I understand that if Young Minds in Motion receives two or more returned checks from my family, they will no longer accept checks as a method of payment.
Young Minds in Motion does not discriminate based on disability in the admission/access to our program.
Consent*
I understand and agree with all the aforementioned terms listed in the Tuition Agreement.
Daily ProceduresAgreement

Please initial each item below:
Attendance (please initial)

I agree to sign the school attendance log when my child arrives in the morning and again when he/she is picked up at the end of the day. No one under the age of 16 is allowed to sign my child in/out of the school.
Illness (Please Initial)

Illness: I understand that I will be notified by school personnel if my child becomes ill during the day and I agree to make every effort to have my child picked up in a timely manner, as the health and safety of all children is of the utmost importance. If my child is exposed to or contracts a contagious disease, I agree to notify the school and I will make certain that he/she does not return to school without written permission from my child’s doctor.
Withdrawal (Please Initial)

Withdrawal from Young Minds in Motion: I have the right to withdraw my child from the program at any time; however, I understand that I must provide a 2-week written notice of withdrawal. If this written notification is not received I agree to pay all the tuition for the 2-week period. I understand that if I then choose to re-enroll my child, she/he will only be readmitted based upon space availability and at the current rate of tuition.
Director Withdrawal (Please Initial)

At the Director’s discretion, Young Minds in Motion has the right to ask a child to withdraw from our program. A a two-week written notice will be given for your child not to return for the following month.
Inclement Weather (Please Initial)

Inclement Weather/School Closings: I understand that it is the Day Cares’ objective to be open during every regularly scheduled school day; however, there are some specific days during which the school will be closed (i.e. federal holidays). In addition, inclement weather and or natural/national disaster or major building issues may necessitate an immediate school closing. This will not affect my child’s tuition in any way.
Consent*
I understand and agree with all the aforementioned terms listed in the Daily Procedures.
Emergency Release and Authorized Escorts List

To maintain the safety of your children, Parents/Guardians must complete, sign, and return this form to Young Minds in Motion upon enrollment. This form shall be updated periodically or when there are changes in the Emergency Release and Authorized Escort information.
Emergency Release Contacts:

Only individuals listed below will be considered as designated emergency release persons. Government-issued ID will be required at the time of pick up. All release persons must be above 16 years of age. Please submit a photo ID of all individuals listed below.
(1) Name
(1) Relationship to Child:
(1) Cell Phone Number
(1) Home Address
(2) Name
(2) Relationship to Child:
(2) Cell Phone Number
(2) Home Address
(3) Name
(3) Relationship to Child:
(3) Cell Phone Number
(3) Home Address
(4) Name
(4) Relationship to Child:
(4) Cell Phone Number
(4) Home Address
(5) Name
(5) Relationship to Child:
(5) Cell Phone Number
(5) Home Address
(6) Name
(6) Relationship to Child:
(6) Cell Phone Number
(6) Home Address
Consent*
I authorize this childcare center to release my child to the individuals I have identified above.
Authorized Escorts List Form
(1) Authorized Escort Name*
(1) Relationship to child*
(1) Home Address*
(1) Preferred Contact Method*
(1) Mobile/Cell Number*
(1) Home Phone Number*
(1) Work Phone Number*
(1) Email*
(2) Authorized Escort Name
(2) Relationship to child
(2) Home Address
(2) Preferred Contact Method
(2) Mobile/Cell Number
(2) Home Phone Number
(2) Work Phone Number
(2) Email
Emergency Treatment Form
Health Insurance Provider:*
Policy #:*
Policy Holder Name:*
Dental Included?*
- Yes
- No
Pediatrician*
Pediatricians Number*
Child Illness Policy

On the average, babies experience eight to ten illnesses a year; preschoolers experience almost as many. We know that managing the demands of work can be challenging when your child is ill. We strive to limit the spread of communicable diseases in our centers and are committed to implementing policies that balance and respect the needs of children, families, and staff in these circumstances. Our Child Illness Policy is based on the Model Health Care Policies developed by the American Academy of Pediatrics. Young Minds in Motion understands that it is difficult for a parent/guardian to leave or miss work; therefore, it is suggested that alternative arrangements be made for occasions when children must remain at home or be picked up due to illness. Exclusion from the center is sometimes necessary either to reduce the transmission of illness or because the center is not able to adequately meet the needs of the child. Mild illnesses are common among children, and infections are often spread before the onset of any symptoms. In these cases, we try to keep the children comfortable throughout the day. Reasons Young Minds in Motion may exclude children include (but are not limited to) the following:
• Illness that prevents the child from participating comfortably in program activities, such as going outdoors.
• Illness that results in a greater need for care than our staff can provide without compromising the health and safety of other children.
• Illness that poses a risk of spread of harmful disease to others
• Severely ill appearance
• Fever of I 00 degrees or above (axillary); IO I or above (orally) or an equivalent measure accompanied by behavior change or other signs and symptoms.
• Fever of I 00 degrees or above (axillary) or IO I or above (orally) in an infant younger than two months; such circumstances should be medically evaluated within an hour
• Fever of I 04° F or greater in a child of any age (requires immediate medical attention)
• Diarrhea; watery stools or decreased form of stool not associated with the change of diet; stool not contained in the diaper; child unable to reach the toilet; or stool frequency that exceeds 2 or more stools above normal for that child.
• Cases of bloody diarrhea and diarrhea caused by Shigella, salmonella, Shiga toxin-producing E coli, Cryptosporidium or G intestinalis must be cleared for readmission by a health care professional.
• Blood or mucus in the stools not explained by dietary change, medication, or hard stools.
• Vomiting more than 2 times in the previous 24 hours (unless the vomiting is determined to be caused by a non-communicable condition and the child is not in danger of dehydration).
• Mouth sores with drooling (unless the child's medical provider or local health department authority states that the child is noninfectious).
• Abdominal pain that continues for more than 2 hours; intermittent abdominal pain associated with fever, dehydration, or other signs of illness.
• Rash with fever or behavioral changes (unless a physician has determined it is not a communicable disease).
• Skin sores weeping fluid and on an exposed area that cannot be covered.
• Purulent conjunctivitis (defined as pink or red conjunctiva with white or yellow eye discharge) until on antibiotics for 24 hours.
• Impetigo until 24 hours after treatment has been started.
• Strep throat (or other streptococcal infection) until 24 hours after treatment has been started.
• Head lice or nits until after the first treatment.
• Rubella, until 7 days after the rash appears.
• Scabies until 24 hours after treatment has been started.
• Chickenpox, until all lesions have dried or crusted (usually 6 days after onset of rash).
• Pertussis (whooping cough) until 5 days of antibiotics.
• Mumps, until 5 days after onset of parotid gland swelling.
• Measles, until 4 days after onset of rash.
• Hepatitis A virus until I week after onset of illness or jaundice or as directed by the health department (if the child's symptoms are mild).
• Tuberculosis, until the child's medical provider or local health department, states the child is on appropriate treatment and can return.
• Any child determined by the local health department to be contributing to the transmission of illness during an outbreak.
For your child's comfort, and to reduce the risk of contagion, we ask that children be picked up within 1.5 hours of notification. Until then, your child will be kept comfortable and will continue to be observed for symptoms. Children need to remain home for 24 hours without symptoms before returning to the program unless the center receives a note from the child's medical provider stating that the child is not contagious and may return to the center. A note from the child's medical provider is required before any child can return to school if they have been absent for two consecutive days or more regardless of the illness. Children who have been absent may return when:
• They are free of fever, vomiting, and diarrhea for a full 24 hours.
• They have been treated with an antibiotic for a full 24 hours.
• They are able to participate comfortably in all usual program activities, including outdoor time.
• They are free of open, oozing skin conditions and/or excessive mucus unless
• the child's medical provider signs a note stating that the child's condition is not contagious, and
• the involved areas can be covered by a bandage without seepage or drainage through the bandage.
• For those children previously suffering from diarrhea or excessively lose bowel movements, readmission can occur when toilet-trained children no longer have toileting accidents and diapered children cease from having diarrhea.
If a child is excluded because of a reportable communicable disease, a note from the child's medical provider stating that the child is no longer contagious is mandatory. Ultimately, the final decision on whether to exclude a child from the program due to illness will be made by the Director at Young Minds in Motion based on the safety or concern for all of the other children. Note: Please be aware that Notes allowing for a child's return to the center after exclusion due to illness must originate from the child's medical provider. A note was written and signed by the child's parent/guardian who is also a physician is not acceptable.
Consent
I agree with the above terms.
Photo Consent Form

Photos are taken daily in our classrooms to capture the milestones that your child achieves. Photos are used for weekly newsletters, our website (both public and private), quarterly parents and family newsletters, and printed marketing materials. Please indicate your permission for consent and sign below.
Young Minds in Motion Parents and Family Newsletter (distributed within center, not visible to the public)*
- Yes
- No
Young Minds in Motion secured Parent Portal website (members only, not visible to the public)*
- Yes
- No
Social media and company website (visible to the public) Facebook, Twitter, etc.*
- Yes
- No
Printed Marketing Materials (visible to the public) Flyers, brochures, magazines, advertisements, etc.*
- Yes
- No
Consent*
I agree to the privacy policy.
NEW STUDENT SUPPLY LIST

Upon entry, the following items are required.Please make certain that all items are clearly labeled with your child’s name, so we can assure that it will be used for your child only. List is subject to change.
•Potty Training Pull-Ups with Velcro on the Sides)
• Baby Wipes
• Seasonal Change of Clothing (pants, shirt, socks, underwear, etc.)
• Two (2) Crib Size Sheets and Two (2) Blankets for Nap-time (23" x 51")
• (1) Pair of Crocs /Garden Shoes
• One supply box with supplies. The student's teacher will provide a list.
Consent*
I agree with the above terms.
Child Health History Form

Hospitalization, Accidents, Illnesses and Medication
Was child ever hospitalized or operated on?
- Yes
- No
Has child ever had a serious accident?
- Yes
- No
Is your child currently taking medication? Which medication?
- Yes
- No
Comments
Has your child ever had or currently have any of the following concerns or does your child complain about any of the following? (Please check all that apply)
- Frequent sore throat
- Frequent cough
- Urinary infections
- Stomach pain, concerns
- Difficulty seeing
- Currently wear glasses
- Ears/hearing
- Seizures, convulsions
Comments
Has your child ever had or does your child currently have any of the following diseases? (Please check all that apply)
- Asthma
- Bleeding tendencies
- Diabetes
- Epilepsy
- German Measles
- Measles
- Heart/Blood Vessel Disease
- Liver Disease
- Rheumatic Fever
- Sickle Cell Disease
- Boils or Hives
- Chicken Pox
- Eczema
- Mumps
- Whooping Cough
- Polio
Comments
Allergies & Other Conditions
This child does NOT have a food allergy that requires restrictions or medications.*
- Yes
- No
This child does NOT have any allergies.*
- Yes
- No
Name of Allergen (pea nuts, eggs, shellfish, etc.)
Previous reactions (rash, lips, swelling, nausea / vomiting, difficulty breathing, anaphylaxis; etc.):
Dietary Restriction
- Complete avoidance
- Avoid in these specific forms:
- Others
Other Dietary Restrictions
Emergency Treatment, if required *
- Epinephrine
- Benadryl
- Other
Other Emergency Treatment:
(2) Name of Allergen (pea nuts, eggs, shellfish, etc.)
(2) Previous reactions (rash, lips, swelling, nausea / vomiting, difficulty breathing, anaphylaxis; etc.):
(2) Dietary Restriction
- Complete avoidance
- Avoid in these specific forms:
- Others
(2) Other Dietary Restrictions
(2) Emergency Treatment, if required *
- Epinephrine
- Benadryl
- Other
(2) Other Emergency Treatment:
(3) Name of Allergen (pea nuts, eggs, shellfish, etc.)
(3) Previous reactions (rash, lips, swelling, nausea / vomiting, difficulty breathing, anaphylaxis; etc.):
(3) Dietary Restriction
- Complete avoidance
- Avoid in these specific forms:
- Others
(3) Other Dietary Restrictions
(3) Emergency Treatment, if required *
- Epinephrine
- Benadryl
- Other
(3) Other Emergency Treatment:
(4) Name of Allergen (pea nuts, eggs, shellfish, etc.)
(4) Previous reactions (rash, lips, swelling, nausea / vomiting, difficulty breathing, anaphylaxis; etc.):
(4) Dietary Restriction
- Complete avoidance
- Avoid in these specific forms:
- Others
(4) Other Dietary Restrictions
(4) Emergency Treatment, if required *
- Epinephrine
- Benadryl
- Other
(4) Other Emergency Treatment:
**If child requires medication for this allergy, please complete the Medication Consent Form for each medication required, and provide the parent with prescription(s) for additional medication to be kept at the childcare program site.
Any allergies to foods, medication, environment, or animals?
Does any of the above affect your child’s everyday activities?
Are there any other conditions that may affect everyday activities that wasn’t discussed above?
Comments
Pregnancy/Birth History
Did mother have any health problems during pregnancy, delivery?*
- Yes
- No
Did mother visit a physician fewer than 2 times during pregnancy?*
- Yes
- No
Was your child born outside of the hospital?*
- Yes
- No
Was your child born more than 3 weeks early or late?*
- Yes
- No
Were there any concerns with the child during or immediately after delivery?*
- Yes
- No
Was the hospital stay extended?*
- Yes
- No
Comments
Consent
I agree with the above terms.
Hospitalization, Accidents, Illnesses and Medication
**If child requires medication for this allergy, please complete the Medication Consent Form for each medication required, and provide the parent with prescription(s) for additional medication to be kept at the childcare program site. **
Does this child have an allergist?*

Yes

No
Name of Allergist:
Phone Number
Health Care Provider (MD, DO, NP, PA):
Date
MM slash DD slash YYYY
Print Name of Health Care Provider:
Address
Fax Number
Phone Number
Consent
I agree to the privacy policy.
Brief Respiratory Questionnaire (BRQ)
In the past 12 months, has your child experienced wheezing or whistling in the chest, or a cough that lasted more than a week?

Yes

No
In the past 12 months, how many times did your child experience wheezing or whistling in the chest, or a cough that lasted more than a week?Number of nights (record “0” if none)
In the past 12 months, how many nights did your child have trouble sleeping because of wheezing or whistling in the chest, or a cough that lasted more than a week?
Please tell us if a doctor, medical care provider, or clinic ever used that name below to describe your child’s condition.
Asthma*

Yes

No
RAD (Reactive Airway Disease)*

Yes

No
Bronchitis or bronchiolitis (bron-kee-oh-lite-iss)*

Yes

No
Asthmatic or Wheezy Bronchitis*

Yes

No
Wheezing*

Yes

No
In the past 12 months, has a doctor, medical provider or clinic prescribed any medicine, inhaler, nebulizer, or breathing machine treatments for any of these conditions, that is for asthma, reactive airway disease, bronchitis or bronchiolitis, asthmatic or wheezy bronchitis, or wheezing?*

Yes

No
In the past 12 months, how many times did your child have an emergency visit to a doctor, clinic or an emergency room for asthma, wheezing, cough, chest tightness, or shortness of breath?
In the past 12 months, how many times did your child have to stay overnight in the hospital for asthma, wheezing, cough, chest tightness, or shortness of breath?
Is your child currently under the care of a doctor, nurse, or clinic for asthma, wheezing, cough, chest tightness, or shortness of breath?*

Yes

No
Does anyone in your household smoke?*

Yes

No
Consent*
I certify that the information above is correct
Significant Family History Is Known*

Yes

No
Mother
Alcohol/Drug Abuse
Asthma
Cancer
Emphysema (COPD)
Depression/Anxiety
Bipolar/Suicidal
Diabetes
Early Death
Heart Disease
High Cholesterol
High Blood Pressure
Kidney Disease
Stroke
Thyroid Disease
Migraines
Others
Father
Alcohol/Drug Abuse
Asthma
Cancer
Emphysema (COPD)
Depression/Anxiety
Bipolar/Suicidal
Diabetes
Early Death
Heart Disease
High Cholesterol
High Blood Pressure
Kidney Disease
Stroke
Thyroid Disease
Migraines
Others
Brother
Alcohol/Drug Abuse
Asthma
Cancer
Emphysema (COPD)
Depression/Anxiety
Bipolar/Suicidal
Diabetes
Early Death
Heart Disease
High Cholesterol
High Blood Pressure
Kidney Disease
Stroke
Thyroid Disease
Migraines
Others
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Early Death
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High Cholesterol
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Child
Alcohol/Drug Abuse
Asthma
Cancer
Emphysema (COPD)
Depression/Anxiety
Bipolar/Suicidal
Diabetes
Early Death
Heart Disease
High Cholesterol
High Blood Pressure
Kidney Disease
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Thyroid Disease
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Maternal GM
Alcohol/Drug Abuse
Asthma
Cancer
Emphysema (COPD)
Depression/Anxiety
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Diabetes
Early Death
Heart Disease
High Cholesterol
High Blood Pressure
Kidney Disease
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Thyroid Disease
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Maternal GF
Alcohol/Drug Abuse
Asthma
Cancer
Emphysema (COPD)
Depression/Anxiety
Bipolar/Suicidal
Diabetes
Early Death
Heart Disease
High Cholesterol
High Blood Pressure
Kidney Disease
Stroke
Thyroid Disease
Migraines
Others
Paternal GM
Alcohol/Drug Abuse
Asthma
Cancer
Emphysema (COPD)
Depression/Anxiety
Bipolar/Suicidal
Diabetes
Early Death
Heart Disease
High Cholesterol
High Blood Pressure
Kidney Disease
Stroke
Thyroid Disease
Migraines
Others
Paternal GF
Alcohol/Drug Abuse
Asthma
Cancer
Emphysema (COPD)
Depression/Anxiety
Bipolar/Suicidal
Diabetes
Early Death
Heart Disease
High Cholesterol
High Blood Pressure
Kidney Disease
Stroke
Thyroid Disease
Migraines
Others
Others
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