About Me - Child Version
It is important to have the current interests of children in mind in order to run a successful play-based, child-led program. This questionnaire serves to help me prepare the environment and myself for your child's first arrival by: providing me with family information, shedding light on what parents/guardians experience at home and how best to support each child. Please answer each question as it pertains to your child.
Name
*
First Name
Last Name
Nicknames (if applicable)
Current Age
*
Parent/Guardian Name(s)
*
Family Size
*
Birth Order (if have siblings - include names & ages)
Family dynamics
*
The patterns of interactions among relatives, their roles and relationships, and the various factors that shape their interactions.
Please share family traditions or significant routines.
*
Ex: after dropping older sibling off at school, we go to the park and play a little before playcare. OR it could be related to a certain holiday, time of year, etc.
How does "discipline" work in your home? Is there one parent/guardian that guides or is responsibility shared equally?
*
Any special words and their meanings that I should know?
Does your child prefer to play independently, with other children, &/or with parents/adults? Please elaborate.
*
Five words that best describe my child are:
*
When we go to the park, my child typically:
*
Please Select
a) Runs off by themselves, without a care in the world what I am doing.
b) Immediately takes my hand and insists I go everywhere with them.
c) Goes off and plays, but reports back to me when exciting discoveries are made.
d) Quickly makes a new friend with another child at the park.
When my child is upset, they need:
*
Please Select
a) to be alone/space
b) a specific stuffed buddy/comfort item
c) held close
d) depends on the situation
Explain what works best from your perspective in various situations (hurt vs mad vs sad etc):
*
Current Interests
*
Favorite Color(s)
*
Favorite food(s)
*
Favorite books, play materials and/or themes
*
Favorite comfort items/loveys
Strong Likes
Strong Dislikes
Fears
Sensory - needs or preferences
When the house is quiet, and I go and check to see what my child is doing, they are typically engaged in:
Piaget’s schema’s are (in a nutshell) a preferred, pre-wired method your child uses to acquire knowledge. Schemas are patterns the brain uses to make sense of the world we live in. By identifying a child’s schema, I can set the environment to better meet their needs. Please check the schema or schemas you feel your child engages in the most:
*
Trajectory: This child is interested in how things and themselves move. If your child seems to always be running around loves to throw things, play with running water or pushing things, they have a trajectory schema.
Transporting: This child is interested in moving everything from one place to another. They may fill containers with random objects for the sheer purpose of carrying them around, they may go back and forth bringing you items from around the house, etc.
Connecting: A child with a connection schema is interested in joining things together, as well as taking them apart. This child enjoys tying things together, constructing things, building and then taking apart thoughtfully (vs scattering).
Envelopment: This child is interested in enveloping themselves and objects. This child loves to wrap up in blankets, make cozy forts, paint themselves, paint a picture and then cover the whole thing with more paint, etc.
Enclosure: This child is interested in making enclosed spaces, but may or may not get in. Very similar to envelopment...yet very different too. This child likes to climb in boxes or fill empty containers but doesn't tend to transport them...for this child, it is clearly about filling containers.
Scattering: Just as the name implies, this child just wants to scatter things about. If your child likes to empty containers, is "a dumpster", loves to knock down towers, may simply just scatter a pile of things on the floor or off the table they have the scattering schema.
Positioning: This is the child that likes to line themselves or objects up in various patterns and configurations. This child may like playing with small objects and lots of pieces, line things up, stack unlikely objects, etc.
Orientation: This child likes to see the world from various perspectives. They may do a lot of tipping of their heads, or climbing on things just to look at the world from there, etc.
Dynamic Vertical: This child chooses goals that are high off the ground. Whether building towers, or climbing to great heights.
What else would you like to tell me about your child?
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform