Student/Family Information Form
This form is required for your child to begin school on August 9th
Please fill out one form PER CHILD attending the ECLC
Child Name
*
First Name
Last Name
Child's Age
*
Child 1 Birthday
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
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Family Information
Full Name of Parent 1
*
First Name
Last Name
Occupation (if work outside the home)
Business Name
Full Name of Parent 2
First Name
Last Name
Occupation (if work outside the home)
Business Name
Names and ages of your child's siblings (please indicate gender, grade level, and if in the home)
Are there any additional/significant members of your household? If so, please include what your child calls them and the role they play in your child's life.
Has there been any significant losses for your child such as death, separation, custody issues, DCF issues? If so, please explain.
List any holidays, family events, and traditions celebrated in your home and why they are important to your child.
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Home Language
Parent 1 First Language
*
Parent 1 Second Language
Parent 2 First Language
Parent 2 Second Language
Language Spoken in the Home
*
Child 1's First Language
*
At what age was your child speaking phrases/sentences in this language?
If applicable, what is the second language your child learned?
Child 2's First Language
At what age was your child speaking phrases/sentences in this language?
*If applicable, what is the second language your child learned?
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Developmental History
Indicate the age at which your child developed the following skills *If applicable:
Sat upright
Crawling
Walking
Toilet-trianed
First words
Get dressed without help
Completing simple chores independently
Is your child adopted?
Yes
No
If so, at what age were they adopted?
Have they been told?
Yes
No
Did/does your child exhibit any of the following?
Poor eye contact
Difficulty getting along with peers
Overly fearful
Would not crawl
Colicky/Irritable
Difficulty adjusting to schedules (eating, sleeping, etc.)
Would not talk
Sleep problems
Resisted affection from others
Poor coordination
Tantrums
Resisted changes in schedule
Accident prone
Stubborn
Overall, as a toddler, how would you describe your child's temperament?
Very easy
Average
Difficult
Extremely Difficult
Have any developmental delays been recognized in your child (social, emotional, physical, verbal)? Has any treatment been initiated (developmental specialist, physical therapy, occupational therapy, etc.)?
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Eating Habits
When did your child begin eating solid foods?
Is your child usually hungry for meals?
What are your child's favorite foods?
What foods are disliked?
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Sleep Habits
What is your child's usual bedtime?
What time do they usually arise?
Does your child nap?
If so, approximately how long does your child nap?
Does your child sleep with a favorite toy?
If so, what is it?
Are there any sleeping problems? If so, please describe:
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Toileting
Is your child toileting independently? If so, at what age did they develop urine control during the day? During the night?
If no, is your child ready to learn to use the toilet?
If yes, why do you think they are ready?
If yes, what toileting words do you use?
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Social Development & Experiences
Please list the prior school/group experiences that your child has had including locations, length of time enrolled, and any pertinent reasons for withdrawal.
How was your child's adjustment to the program?
If there have not been any prior school experiences, please tell us what your child knows about school.
Which of the following behavior characteristics would you say your child exhibits most often?
Calm
Excitable
Easily Angered
Whiny
Crying
Happy
Stubborn
Cheerful
Quiet
Cooperative
Independent
Active
Fights often
Gives in easily
Wants their own way
Temper tantrums
Other
What are you child's favorite toys, activities, places to go, games to play, or other interests?
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Emotional Development
Does your child have any fears? If so, describe the fears and how you handle them.
If your child is not yet a toddler you can fill this in with n/a
Does your child have any comfort items or any specific ways of calming themselves down when they get upset?
If your child is not yet a toddler you can fill this in with n/a
What most often makes your child angry?
If your child is not yet a toddler you can fill this in with n/a
Have there been any recent hospitalizations, deaths in the family, separation from parents or other situations which might affect your child's adjustment to the Center at this time? If so, please explain:
If your child is not yet a toddler you can fill this in with n/a
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Family History
Has either of the child's biological parents experienced any of the following conditions?
Attention-Deficit/Hyperactivity Disorder
Learning disabilities/Academic underachievement
Obsessive-compulsive disorder
Depression
Autism/Asperger's Syndrome
Substance abuse
Communication disorders/disabilities
Sulfa drugs
Tourette Syndrome
Anxiety disorders
Behavior problems
None
Other
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Additional Information
What are goals and any concerns you have regarding your child during this program year?
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