Child Information Sheet
This sheet will help us learn more about your child and how we can better care for them during the school year.
Child's Name
*
First Name
Last Name
Nickname, if any you would like teachers to use in the classroom
*
Date of Birth
*
/
Month
/
Day
Year
Date
Child's Likes
*
Child's Dislikes
*
Child's Special Care Needs (check all that apply)
*
Environmental allergies
Food intolerances
Existing illness
Previous serious illness
Injuries and hospitalizations (in past 12 months)
Limitations or restrictions on child's activities
Reasonable accommodations or modifications
Adaptive equipment (please include instructions below)
Symptoms or indications of complications
Medications prescribed for continuous long-term use
None of the above apply to my child
Other
Explain any needs selected above or write none if none have been checked.
*
Does your child have diagnosed food allergies?
*
Yes
No
If yes, please list food allergies. An Allergy Action Plan must be on file along with the child's medications before your child's first day of attendance.
List any special problems that your child may have such as non-food allergies (list food allergies above), existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medications prescribed for long-term continuous use, and any other information which caregivers should be aware of (or write N/A):
*
Is your child currently going to therapy or is being evaluated? If so, please explain so that we can better support your child while in our care.
*
Has your child been in school or been left in someone else's care?
*
How would you describe your child's personality?
*
Is child potty trained?
*
Yes, 100% during the day.
No
Child is currently learning.
Does child have a pacifier or security item? If so, what?
*
Does child nap?
*
No
Every day
Occasionally
Children over 18 months of age do not nap during our regular school day (9:00-1:30). If your child is UNDER 18 months, please indicate WHAT TIME AND HOW LONG your child typically naps to help your child's teacher plan an appropriate schedule for the group.
Anything you would like to share about your child's feeding that might help teachers in caring for them? Any dietary restrictions?
*
List 3 skills/areas that your child does well:
*
List 3 skills/areas for growth this year:
*
Home Life
Tell us more about your family and your household.
Father's Name
*
First Name
Last Name
Father's Occupation
Mother's Name
*
First Name
Last Name
Mother's Occupation
Who does child live with?
*
Both Parents
Mom
Dad
Other
Siblings and their ages, or other persons who live in your home
*
Any pets in your family?
*
Are there any major life changes or situations going on in the home that might be stressful to your child?
*
Is there anything else you would like to share about your child that will help their teachers care for them? Any concerns or comments?
Form completed by
*
Email of Parent Completing Form
*
example@example.com
Date completed
*
/
Month
/
Day
Year
Date
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