| You are our most important resource! This form is used
by your child's teacher to better understand and meet your child's
individual needs. Because your child is continuously growing and changing,
we would appreciate your time in filling out this form completely.
Your answers will be confidential. Please do not feel obligated to
answer any questions that you think are too personal. |
| Child's name |
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| Date of birth |
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| Place of birth |
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| Name your child would like to be called: |
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| Name of parent(s)/guardian(s): |
| First |
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| Last |
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| Date of birth |
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| First |
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| Last |
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| Date of birth |
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| Address |
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| City |
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| State |
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| Zip |
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| Telephone |
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| Email |
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| Please indicate the name by which
parent(s)/guardian(s) preferred to be called: |
| Parent/Guardian 1 |
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| Parent/Guardian 2 |
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| Marital status |
Married
Single
Divorced/Separated
Widowed |
| In which house does your child reside? |
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| What language does your child speak? |
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| Please list, in order of birth, all children (including
this child) in your family: |
| Name |
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| Sex |
Male
Female |
| Age |
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| |
| Name |
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| Sex |
Male
Female |
| Age |
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| |
| Name |
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| Sex |
Male
Female |
| Age |
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| Name |
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| Sex |
Male
Female |
| Age |
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| Please list any other persons (and their relationship)
living in your household |
| Name |
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| Relationship |
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| |
| Name |
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| Relationship |
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| Name |
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| Relationship |
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| Does your family have any pets? Please list the kind
of pet and its name: |
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| Has your child had any previous school, playgroup,
day care or baby sitter experience? (Please indicate what type of experience.) |
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| Was this a positive experience? |
Yes
No |
| Is your child currently participating in any of the
above? (Please name and describe setting.) |
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| What are the favorite activities in which your child
participates with other family members? (Please note which family member
participates.) |
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| Discipline |
| What are your usual methods of disciplining your child? |
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| What method does your child respond to best? |
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| Do you have any particular discipline concerns you
would like us to be aware of? |
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| Does your child have a regular babysitter other than
family members? If so, please give name: |
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| Allergies |
| Does your child have any allergies? |
Yes
No |
| If yes, to what? |
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| What are the symptoms/effects of the allergy? |
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| What is the treatment? |
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| What allergies run in your family? |
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| Does your child have any special medical conditions
(such as eczema, epilepsy)? |
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| How does your child relate... |
| to adults? |
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| to men? |
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| to women? |
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| Does your child have any favorite play companions or
imaginary friends? Please explain. |
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| Have there been any major changes in the family, such
as medical problems, moving, divorce, etc. which may have affected
your child? Please explain. |
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| Do you have any concerns regarding your child's physical
or emotional development? |
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| Does your child have any particular fears, such as
loud noises, lightening, animals, etc? Please describe. |
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| What is your usual method of reassuring and rewarding
your child? |
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| What are some of your child's favorite activities,
interests and toys? |
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| Eating |
| Do you have any particular concerns about your child's
eating habits/schedules? |
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| List your child's favorite snacks: |
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| Toileting |
| Is your child trained for urine? |
Yes
No |
| Is your child trained for bowels? |
Yes
No |
| What words does your child use to describe the process
(e.g. "poop")? |
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| Does your child use an adult size toilet at home? |
Yes
No |
| If your child is being potty trained, what are the
methods you use and what stage is your child at in this process? |
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| Are there any specific concerns or tips you can give
us regarding your child's bathroom habits that would be helpful to
us? |
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| Sleeping |
| Does your child nap at home? |
Yes
No |
| At what time(s)? |
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| How long? |
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| If your child is in attendance during room nap times,
do you want your child to nap here? |
Yes
No |
| For how long? |
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| What is your accustomed manner of putting your child
to bed (e.g. warm bottle, cold bottle, no bottle, rocking, reading
a story, singing, blanket, pacifier, toy)? |
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| What is his/her nighttime sleeping schedule? |
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| Parent |
| Do you (parent/guardian) have any resources, hobbies,
interests or skills you would be willing to share with the room (e.g.
baking bread, playing an instrument, "tools of the trade",
etc.)? |
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| What is your (parent/guardian) occupation? |
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