Learning Together Preschool Learn ~ Grow ~ Thrive
Child and Family Information
Name of Child:________________________________________________________________
Date of Birth:__________________________________________________________________
Address:______________________________________________________________________
Home Telephone:_______________________________________________________________
Mother’s Name:_________________________________________________Age:___________
Work Phone_____________________________________Cell Phone:_____________________
Occupation:____________________________________________Work Hours:_____________
Father’s Name________________________________________________________Age:______
Work Phone_____________________________________Cell Phone:_____________________
Occupation:____________________________________________Work Hours;_____________
Guardian’s Name___________________________________________________Age:_______
Work Phone_____________________________________Cell Phone:_____________________
Occupation:____________________________________________Work Hours:_____________
Marital Status of Parents:
_____Married, Living together
_____Married, Separated
_____Partners, Living together
_____Divorced
_____Step Parent
____Guardian
(Please explain)___________________________________________________________________________________________________
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Custody/Visiting Arrangements (if applicable):___________________________________________________________________________
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Is child adopted?_____Does he/she know?__________Age at adoption:____
Siblings of your child:
Name:__________________Age:_____ Name:___________________Age:_____
Name:__________________Age:_____ Name:___________________Age:_____
Other members of household (include names and relationships)
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Does child have own room?______If not, with whom?______________________________________________________________________
What experience does your child have with other young children__________________________________________________________________________________________________________
Briefly describe your child’s personality:_______________________________________________________________________________________________________
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What are your child’s favorite interests? ________________________________________________________________________________
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What are your child’s favorite indoor and outdoor activities? _________________________________________________________________
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Does your child have any special fears you are aware of?_____What are they? _________________________________________________
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What do you enjoy most about your child?______________________________________________________________________________
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What do you find most challenging about your child?_______________________________________________________________________
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What method of behavioral management is used in your home?
_____________________________________________ __________________________________________________________________
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What is your child’s usual reaction? ___________________________________________________________________________________
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What other information about your child is important for us to know? __________________________________________________________
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Health & Diet
Is child allergic?_____ If yes, how does it usually manifest itself (asthma, hay fever, hives, other)?
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Has child ever been to the dentist?__________Has child had vision tested?_________
Has child had hearing tested?__________Does you child need special medication? ______
Please explain:___________________________________________________________________________________________________
Please give a statement of your child’s over all health:
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Is your family vegetarian?_____Please list other dietary restrictions:__________________________________________________________
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Developmental History
Does child dress self?_____ Undress self?_____ Right or left handed?_____________
Is your child toilet trained?_____
At what time does your child usually go to bed at night?________ Awaken?_________ Nap?________
Does your child sleep well?________ Play with water?________ Go barefoot?_______
Does your child have any speech problems? _______________________________________________________________________
Thank you for your time and energy filling out this information. Your information will help us better serve your child.