Preschool Registration Form
Child's First Name:
*
Child's Last Name:
*
Child's Preferred Name:
Child's Date of Birth:
*
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Month
-
Day
Year
Date
Has your child attended preschool before?
*
Yes
No
Preschool Name:
Parent or Legal Guardian #1 Full Name:
*
Parent or Legal Guardian #1 Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent or Legal Guardian #1 Phone:
*
Please enter a valid phone number.
Parent or Legal Guardian #1 Email:
*
example@example.com
Parent or Legal Guardian #2 Full Name:
Parent or Legal Guardian #2 Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent or Legal Guardian #2 Phone:
Please enter a valid phone number.
Parent or Legal Guardian #2 Email:
example@example.com
Emergency Contact Name:
*
Emergency Contact Phone:
*
Please enter a valid phone number.
Allergies or Dietary Restrictions:
Are there other children living in the home?
*
Yes
No
If yes, please list names and ages.
Is your child potty trained? (This is not a requirement but helps us plan accordingly.)
*
Yes
No
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Student Background Information
Please help us get to know your child. At Connected Kids Preschool, we set very specific goals foreach individual. The more we know about your child’s history and particular needs, the more effectively we can support their learning. (Not all questions will apply to your child.)
Trauma History
Please disclose as much or as little as you are comfortable sharing. (Check all that apply.)
Prenatal History:
*
Medical Trauma
Alcohol exposure
Difficult birth
Homelessness
Drug exposure
Prematurity
Malnutrition
Domestic Violence
None of the Above
Other
Trauma History Birth to Present:
*
Medical trauma or neglect
Homelessness
Abuse
Sexual Abuse
Malnutrition
Domestic Violence
Abandonment by one or both parents
Death of a parent
None of the above
Other
Special Services: Please check any interventions your child has received in the past or is currently receiving:
*
Speech Therapy
Occupational Therapy
Vision Therapy
Counseling / Play Therapy
Physical Therapy
None of the above
Other
Are there any other circumstances or issues that we need to consider?
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Placement Information
This section ONLY applies to children currently in state custody.
How long has your child been in state custody?
At what age was your child taken into custody?
How long has your child been in your home?
How many placements has your child had?
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Behavior Survey
This section applies to ALL children.
What makes your child happy?
What are your child's favorite activities?
What fears does your child demonstrate?
Is there anything that triggers a meltdown or anxiety? What strategies do you use at home to help your child calm down and feel safe?
Are there any specific concerns that you have concerning your children's growth and development?
Signature
*
Date Signed:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: