Transition Form
Which location is your child enrolled at?
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Please Select
Special Beginnings Early Learning Center - Lenexa
Special Beginnings Early Learning Center - Olathe
Special Beginnings Early Learning Center - Overland Park/Cleveland Chiropractic College
Child's Full Name
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First Name
Last Name
Name(s) child is called at home
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Gender
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Male
Female
What age ranges does your child fall in?
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Please Select
Infants 1:
Infants 2:
Toddlers 1:
Toddlers 2:
Preschool:
Preschool 3:
Preschool 4:
Pre-Kindergarten:
Parent/Family Information
Parent/Guardian 1 Full Name:
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Home Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2 Full Name
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Home Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Parents are:
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Married
Divorced
Separated
Single
Please list any step parents or other adults who will be regularly dropping off or picking up your child.
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How long has your child been at Special Beginnings?
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If new to the class, how do you feel your child will adjust to our setting?
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Please list names and ages of siblings:
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Names and kinds of pets at home:
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Has your child been in group care prior to Special Beginnings?
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Yes
No
If yes, what type?
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Health
Does your child seem well most of the time?
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Yes
No
Is your child on any type of medication? Please include vitamins, laxatives, gas drops, etc.)
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Yes
No
If yes, what medication and why is it given?
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Since birth, has your child had any ear infections?
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Yes
No
If yes, how many?
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Are you concerned about your child's hearing?
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Yes
No
Since birth, has your child had more than 3 sore throats, colds, or fevers?
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Yes
No
Are you concerned about your child's eyes or vision
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Yes
No
Has you child been see by a medical specialist?
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Yes
No
If yes, who and why?
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What arrangements have you made for the care of your child if he or she should become ill while attending the center?
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Does your child have any handicaps?
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Yes
No
Does your child have any health related issues that we need to be aware of?
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Yes
No
If yes, please explain
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Has your child been hospitalized?
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Yes
No
If yes, please list dates and explain reason
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Has your child had any serious accidents or poisonings
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Yes
No
If yes, please explain
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Has your child had any of the following:
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Premature birth
Trouble breathing at birth
A birth defect or injury
Head injury
Convulsions/Seizures
Allergies of any kind
NONE
Other
Please describe in detail your above selections
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Does your child have all of his/her teeth?
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Yes
No
Is your child currently teething?
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Yes
No
Is your child prone to biting when angry or frustrated?
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Yes
No
Does your child have any allergies or other health related issues?
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Yes
No
If yes, describe:
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Getting to Know You
How do you comfort your child?
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What are your child's favorite toys?
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What are your child's favorite activities?
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What language(s) are spoken in your home?
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How do you help your child go to sleep?
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Does your child cry when going to sleep
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Yes
No
What is your child's current sleep schedule?
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Rows
Start Time
End Time
Night Time
AM Nap(s)
PM Nap(s)
Kansas Department of Health and Enviornment requires that all children sleep either on their back or side while in childcare. Which does your child prefer?
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Back
Side
Does your child use a pacifier at naptime?
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Yes
No
Does your child use a pacifier while awake?
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Yes
No
If yes, what does your family refer to the pacifier as (binky, pacy, yummy, etc.)?
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Does your child normally take a nap?
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Yes
No
Are you trying to discourage the daily nap?
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Yes
No
What does your child's sleep schedule typically look like?
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Rows
Start Time
End Time
Night Time
Nap
What items does your child use to relax at naptime?
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Please tell us what your child calls them:
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Are you trying to discourage the use of amy of these items?
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Yes
No
Feeding
Is your baby breast or formula fed?
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Breastfed
Formula fed
Both
If formula is used, what brand and type (powder, concentrate, etc.)
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Type of bottle
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Type of nipple
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How often do you burp your baby?
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What is your child's present eating schedule? Please list all juices, foods, formulas, snacks, including times and amounts:
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Does your child have any feeding problems?
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Yes
No
If yes, please explain
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What is your child's present diet and eating schedule?
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Rows
Types of foods
Time
Breakfast
Lunch
Dinner
Snack
Are there any foods that your child refuses?
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Diapering / Potty Training
How frequently does your child have a bowel movement?
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Appearance of a "normal" bowel movement:
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Does your child have diaper rash often?
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Yes
No
How is it treated?
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Are there any brands of diaper cream that you prefer us to use?
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Are there any brands that you prefer we not use?
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Does your child have any reactions to certain diapers, diaper wipes?
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Is your child potty trained?
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Yes
No
If not, are you currently working on potty training?
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Yes
No
If yes, please describe the methods you are using at home (i.e. sticker chart, potty treats, etc.)
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Child's Personality
What seems to be your child's favorite activities?
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Please describe your child's personality:
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How does your child react when angry and/or frightened?
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Please select the words that tend to describe your child’s personality:
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Cheerful
Strong-willed
Cooperative
Passive
Aggressive
Independent
Quiet
Social
Active
Happy
Frustrates Easily
Tolerant
Sometimes Whines
Slow to Anger
Energetic
Please list any additional information you would like to share with us about your child.
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Submit
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