Child's Family Information Sheet

Our teachers would apprecaite knowing about your child and family so that they may be aware of your child's unique needs and circumstances.

Child's Name: *

Nickname:

Sex: *

Birthdate: * +

Mother's Name:

Father's Name:

Home Phone:

Names and ages of siblings:

Adults who live in the home with your child:

Please list the names and kinds of pets in your home:

My child's favorite activities include:

My child's least favorite activities include:

My child's strengths include:

Does your child have a job at home:

Does your child have any fears?

Does your child have a security item?

As teachers, you can help my child most by:

My child needs help with:

Has your child experienced any emotional distress in the recent past?

Is your child receiving any special services from County agencies or from a private source?

What opportunities has your child had to play with other children?

This year I would like my child to:

I would like you to know that:

We are required by licensing regulations to obtain the following information on previous enrollment in school or daycare. If a question does not apply to you, please write n/a in space provided.

Is this your child's first year in school? *

Yes

No

Please give the name and location of precious school(s) and number of year(s) attended. *

Has your child ever been with a caregiver during the day? *

Yes

No

If your child is currently with a caregiver, please indicate the number of hours: *

Care is provided at: *

How many other children are with the caregiver? *