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Date (Month, Day, Year)
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Time
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Child's Age
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Child's Birthday
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Child's Nickname
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Address (street, city, state, zip)
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Contact Information
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Mom's Name
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Dad's Name
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(Mother) Home Phone
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(Mother) Work Phone
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(Mother) Cell Phone
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(Dad) Home Phone
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(Dad) Work Phone
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(Dad) Celll Phone
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Emergency Contact Person (Name and Cell Number)
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Backup Contact Person (Name and Cell Phone)
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Your Child's Health
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Are your child's immunizations up to date?
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Does your child have any know allergies? If so what are they.
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Does your child have any medical conditions that we should be aware of? If so what are they.
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Does your child have any problems with following?
Constipation
Convulsions
Diarrhea
Fainting Spells
Frequent Colds
Frequent Ear Infections
Frequent Sore Throats
Lice
Ringworm
Skin Rash
Soiling
Stomach Upsets
Uninary Problem
Worms
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Has your child had or have any of these diseases?
Asthma
Bronchitis
Chicken Pos
Diabetes
Heart Disease
Hepatitis
Impetigo
Measles
Mumps
German Measles
Polio
Scarlet Fever
Tuberculosis
Whooping Cough
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Does your child have any speech, hearing or problems.
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Does your child have any restrictions to play or activities?
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About Your Child
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How do you think your child will feel about being left at school by his mommy or daddy?
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Are there any recent traumatic situations that your child has been exposed to such as death in the family, divorce, new sibling, etc.? If so explain
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What is your normal method of discipline? Explain
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What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc. (Please be honest. We are here to help.)
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Does your child have any food restrictions? If so explain.
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What is your child's favorite food?
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Can your child be relied upon to indicate bathroom wishes? :)
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Does your child have siblings? Please give names and ages.
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Has your child had experience playing with other children? (Other than siblings)
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What language(s) are spoken at home
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Does your child have any security objects such as a blanket, soother, bottle, toy, etc.? If so explain. (Please be sure they bring it with them to class daily to class)
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What are your child's favorite activities, toys, books or games?
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Are there any other comments or information you would like us to know about your child?
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Do you have any concerns about them starting the program? If so what are they.
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Mom's Email Address
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Dad's Email Address
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