Family Information Form

Child's Name: *

Name of Parent filling out form: *

This child was potty trained at age: *

Has this child ever had a hearing test? *

Yes No

Date of Hearing Test:

Hearing test results:

Has this child ever had an eye examination? *

Yes No

Eye examination date:

Eye examination results:

Does your child: (mark all that apply) * (1 required)

Jump (with 2 feet) Hop Skip Gallop Walk up and down steps

Describe your child's favorite playmates (i.e. solitary, siblings, peers, adults) *

Describe your child's favorite activities (i.e. toys, games, books) *

Does your child use screens (TV, tablet, phone, computer, or gaming device)? *

Yes No

What types of screen content does your child enjoy most? (Examples: educational programs, cartoons, movies, YouTube, games, video chats)

Does anyone read stories to this child? *

Yes No

If yes, who?

How often?

What will be your child's typical morning routine and drop off routine before coming to school? *

Please take a moment to describe your child’s personality and temperament to us: *

Please describe the type of discipline for behavior you use at home: *

What makes your child angry or upset? *

What calms your child when he/she is upset? *

What things make your child happy? *

What are three strengths you see in your child? *

Are there religious or family/cultural traditions your child observes? *

Yes No

If yes, please specify:

Please describe any circumstances that may be influencing your child's current behavior (e.g., a new sibling, move, illness, family changes). *

Who are the important people in your child’s life not listed in previous admissions forms? *

The child has attended (check all that apply): * (1 required)

Preschool Daycare Home Childcare Other None of the above

If other, please specify:

How has daytime childcare been provided in the past? (check all that apply) * (1 required)

Parent Grandparent Other Relative Daycare Home Daycare Center Preschool Nanny Other

Are there pets in the home? *

Yes No

If yes, please specify:

Is English your child's primary language? *

Yes No

If no, what is the primary language?

Describe your child's language and communication abilities: *

If English is the second language, how does your child communicate the following:

"I need to use the bathroom"

"I don't feel well or am sick"

"I am tired"

"I feel sad"

"I am thirsty and need a drink"

Does your child have fears we should know about?

Yes No

If yes, please specify and provide tips for helping your child cope with them.

What are your child's eating habits and routines? *

What are your child's food likes and dislikes? *

Does your child have a current Individual Education Plan (IEP)? *

Yes No

If yes, please explain:

What do you hope your child gains from enrollment in our program? *

Thank you for your time and patience in filling out this questionnaire. Your responses will be held in the strictest confidence. Responses will be shared with the classroom teacher to enable us to meet your child's needs, concerns, and transition to school.

Enter Your Email Address: *

This page is for families of currently enrolled preschool students. Please do not fill out this form until you are instructed to do so.