Early Education Questionnaire

Early Education Questionnaire

Ages 0-4
Child's Full Name

First Name Last Name
Age
Classroom (please note that class transitions occur based on spot availability and not necessarily by exact age)

Infants/Babies (ages 0-2) Toddlers (ages 2-3) Preschool (ages 3-4) Pre-K (ages 3.5-4.5) Kinder-Ready (ages 4.5-5.5)
Parent/Guardian Full Name

First Name Last Name
Today's Date

Month Day Year
Date

HEALTH & SAFETY
1. Does your child have a medical need we should be aware of?
2. Does your child require any medication(s), lotions, creams, or ointments while in care? If so, please explain. Please also complete the "Medication Authorization Form" available at the bottom of our enrollment webpage: www.creativecareeugene.org/enrollment
3. Does your child have any allergies of any kind? If so, please list.

FAMILY CULTURE

(this section is optional)
1. OPTIONAL - What are the names and ages of all people who live in your home and their relationship to your child? Please include family pets.
2. OPTIONAL - Please list all ethnicities/cultural background(s) for your child/family
3. OPTIONAL - What is your child/family primary language?
4. OPTIONAL - Does your family celebrate or observe any special traditions or holidays? If so, please list and describe.
5. OPTIONAL - Are there any traditions, holidays or observances that your family avoids? If so, please list. Please see Eugene Creative Care’s policy on "Holidays and Observances" in our Family Handbook.
6. OPTIONAL - Is there anything else that you would like to share about your family structure, beliefs, and traditions?
Eugene Creative Care extends the invitation to you the parent or any extended family member who is authorized on your enrollment agreement to share any special traditions, talents, or skills you would like to share with your child’s class. Visits of this nature must be pre-arranged with the Center Director and your child’s teacher.

FEEDING & MEALTIME ROUTINES
1. Please mark your child's mealtime routine (please update with your teacher as your child progresses)

Breastfed Bottle Soft-solids (jar or mashed) Solids (finger or standard)
Please note, if your child is breastfed, we encourage mothers to visit our nursery to feed their child as often as they would like. Pumped breast milk must come already expressed into premeasured bottles which Teachers will store in a refrigerator until the time of use. Please label this with your child's name and the date. If your child is formula or jar food fed, families are responsible for providing these foods on a regular basis. Formula does not need to be premixed. All bottles and jar foods will be warmed according to your child’s schedule and family preferences by a bottle warmer located inside the classroom. Empty used bottles, whether containing breast milk or formula, will be placed with your child’s belongings after each use. Bottles are not cleaned or sterilized at our facility. If you would like your child’s teacher to save used food jars for you, please let them know. Table foods are provided by the center unless your child or family has or prefers a special diet other than what is listed on the monthly service menu.
2. What position is your child familiar with while eating?

Holding/rocking Baby chair (self or teacher fed) Baby chair (fingers or utensils) Table with utensils
Our programs offer family style meal service for toddler and preschool age children. This means we encourage self-serving, individual child size place settings, and casual conversation while dining.
3.a. Describe how you prepare and serve food/bottles for your child
3.b. Amounts & how often:
NOTE: Infants feeding schedules change frequently, please keep your child’s teacher informed of new feeding schedules and foods.
4. Is your child a considered a "picky eater" or experience eating difficulties? If so, please explain
5. Please list specific food favorites
6. Please list specific food dislikes

SLEEP/REST SCHEDULE
1. When, how often, for how long and at what times does your child sleep/take a rest?
2. Is your infant always put to sleep on his/her back?
3 How does your child show signs of needing to sleep/rest?
4 What routines and techniques do you use to put your child to sleep/rest?
5. What is your child’s wake up routine/temperament/needs?

BATHROOM ROUTINE
1. Please mark your child's level of toileting needs (mark multiple if you are working on accomplishing a new task)

Diaper Pull-Up Potty Training Fully Potty Trained
Diaper size (if applicable):
2. If your child is potty training, please tell us about his/her routine or methods currently being used at home, and how you would like us to support this in the classroom.
3. Can your child change his/her own clothing in the event of a soiling accident?
4. Please describe your child’s reactions to soiling their clothing (hiding, crying, resistance to changing, lets an adult know, etc)?
Diapers, specialty wipes other than what brand our site uses, diaper cream if needed, pull ups, and at least two extra sets of clothing should be kept at the center and replaced on a weekly basis. You should communicate with your child’s teacher to determine the quantity and what your child’s needs will be. Diapering checks will be performed no less than once per hour, if not more. The diaper will be changed regardless of how full it may be on a 2 hour or less basis.

CHILD DEVELOPMENT
1. Does your child have a diagnosis regarding a developmental area or need?
2. Does your child have trouble in any developmental area in which we can help promote growth? If so, please explain.
ECC works in partnership with parents to conduct the Ages and Stages Developmental Questionnaire (ASQ-3) with your child within 30 days, after 6 months and then annually to help ensure your child is making healthy strides in his/her development.
3. How do you comfort your child when he/she is upset?
4. Please describe your child’s language level (words, sentences, conversational)
5 Please describe your child's favorite games, toys, interests, and activities
6. Are there any concerns or anything not covered here that you would like us to know about your child?
~ Welcome to Fairfield Child Development Center! ~
Should be Empty:

Early Education Questionnaire

HEALTH & SAFETY

FAMILY CULTURE

FEEDING & MEALTIME ROUTINES

SLEEP/REST SCHEDULE

BATHROOM ROUTINE

CHILD DEVELOPMENT