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Student
Information Form
Child’s given name:
_______________________________
Name child is called: __________________________
Parent Name (s):
_____________________________________________________________________________
Address:
_____________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Telephone Number:
(_______)________________
HOME AND FAMILY
Child’s birthdate:
_______________________
Place of Birth: ___________________________________
Is the child adopted? _______________
At what age? _____________ Does
he/she know? _________________
Father’s Name:
______________________________ Occupation:
______________________________________
Mother’s Name:
_____________________________
Occupation: ______________________________________
Any other adult’s in the home?
_________________________________
Anyone (other than the parents) who
has had a substantial role in child-rearing?____________________________
Siblings:
Brothers
Age
Sisters
Age
_____________________________________
_______________________________________
______________________________________
_______________________________________
_______________________________________
______________________________________
What duties or responsibilities
does the child have each day?__________________________________________
___________________________________________________________________________________
HEALTH AND GROWTH
Child’s weight at birth:
_______________ Delivery:
Normal __________ Complications?
_______________
Does your child have any food
allergies? Specify:
__________________________________________________
Any other allergies?
Specify:
___________________________________________________________________
Daily routine:
Bedtime: ________________________
Rises at _______________ Naps:
__________________
At what age was bowel control established?
__________________________________________________
At what age was bladder control established?
_________________________________________________
Does your child have opportunity to
play with live animals? ___________________________________________
List any pets in your home?
_____________________________________________________________________
Any difficulty with hearing?
___________________________________
with vision? ______________________
Any serious injuries?
_________________________________________
any surgeries? ____________________
Have
any of the following been a problem for your child?
____ Thumbsucking
____ Bedwetting
____ Elimination
____ Eating
____ Sleeping
____ General Nervousness
Any
health problems at present?
_________________________________________________________________
MOTOR
DEVELOPMENT
At
about what age (in months) did your child begin to crawl?
__________________________________________
At
about what age (in months) did your child begin to walk?
___________________________________________
Hand
Preference: Left
________________ Right
___________________ No
Marked Preference ____________
Has
your child had experience with any of the following materials?
____ Crayons
____ Scissors
_____ Pencils
____ Paint
____ Paste of glue
_____ Liquid crayons
or magic markers
PLAY
ACTIVITIES
What
are your child’s favorite play activities?
___________________________________________________
Any
make-believe play? __________________________
Play outdoors regularly? _____________________
How
many hours a day does your child watch television?
__________________________________________
List
favorite programs:
______________________________________________________________________
Does
your child enjoy children’s tapes? _______________________
Does your child sing? ________________
How
would you characterize your child’s play at home?
_____ Active
_____Quiet
____ Energetic
____Boisterous
_____ Self-Initiated
_____ Dependent on adults
List
any play restrictions we must follow for your child: (i.e. health
problems) _________________________
__________________________________________________________________________________________
SOCIAL
INTERACTIONS
About
how much time each day does child spend with mother?
__________________Father? _______________
About
how much time each week does your family spend doing things together,
such as visit the zoo, a park, museums,
walks,
playing?______________________________________________________________________________
Does
your child have playmates? _______________________________
How many? _____________________
What
are sex and age ranges of these playmates?
___________________________________________________
How
does your child interact with these playmates?
_________________________________________________
SPEECH
AND LANGUAGE DEVELOPMENT
At
about what age (in months) did your child begin to say words?
______________________________________
At
about what age (in months) did your child begin use 3 word sentences?
_______________________________
Any
apparent speech difficulties? Describe
briefly: _________________________________________________
___________________________________________________________________________________________
Do
you read to your child? _____________________ How often?
______________________________________
What
type of story does your child enjoy?
__________________________________________________________
EMOTIONS
AND BEHAVIOR
Does
your child have any of the following fears?
______ of the dark
_____ of strangers
______ of animals
______ of being alone
_____ of storms
______ of medical personnel
How
would you characterize your child’s general attitude towards adults?
_____ friendly
_____ aggressive
_____ shy
_____ indifferent
Does
your child: _____ take care of toilet needs _____ put on own coat
_______button
_____zip
How
do you asses your child’s confidence?
_____________________________________________________
Has
your family gone through any difficult situations such as a fire,
robbery, death in the family circle? ______
_________________________________________________________________________________________
How
does your child react to new situations?
________________________________________________________
_____________________________________________________________________________________________
DISCIPLINE
What
points are most often at issue between parent and child?
___________________________________________
_____________________________________________________________________________________________
What
method do you use for conflict resolution?
______________________________________________________
How
does your child react?
_______________________________________________________________________
LIFE
EXPERIENCES
Has
you child ever been separated from you for any length of time?
______________________________________
If
so, how did you child adjust?
___________________________________________________________________
Has
your child had any of the following travel experiences?
_____ automobile
_____ airplane
_____train
_____ bus
_____ boat
_____ subway
List
frequent travel experiences:
____________________________________________________________________
List
major or distant travel experiences:
______________________________________________________________
Has
your child had any experiences in a supervised group such as daycare,
nursery school, Sunday school, etc.? _____
_______________________________________________________________________________________________
Does
your family attend church? ______________________
Which one? ___________________________________
ADDITIONAL
COMMENTS
Is
there anything else you feel we should know as we work with your child?
_________________________________
_______________________________________________________________________________________________
How
do you feel your child will benefit from attending Little F.O.L.C.s
Preschool? ___________________________
_______________________________________________________________________________________________
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