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INFANT PERSONAL CARE PLAN
DEVELOPMENTAL HISTORY FORM
1
Today’s Date: __________________________ Date of Enrollment/Transition: _______________________
Child’s Name: _________________________ Date of Birth: ________________ Age: ________________
Date of Last Physical (for WA State only): _____________________________________________________
What would you like us to call your child?:_____________________________________________________
Parent/Guardian Name: ______________________________________________________________________
Parent/Guardian Name: ______________________________________________________________________
Name of Person Completing Form: ____________________________________________________________
Primary Caregiver: __________________________________________________________________________
Classroom: __________________________________________________________________________________
FAMILY INFORMATION
If parental custody is shared, describe the custody arrangements: ___________________________
Please tell us about cultural family customs, rituals, or traditions that will help us make your
child’s experience more meaningful, including languages spoken at home: ____________________
In the columns below list the names of family
members residing with the child. Please include
siblings, extended relatives, and pets. For each
person listed provide the name the child uses
to address that individual and include ages of
siblings.
Name
How child addresses
this individual? Age
Please list the words used in your
language corresponding to the words in
English. Include additional words in the
blank columns if needed.
I’ll take good care of you
I see that you are crying
Let’s change your diaper
I like your smile
It’s time for your bottle
Time to eat
Time for your nap
Mommy will be back
Daddy will be back