Love One Another

2031 W. Northwest Hwy Grapevine, TX 76051

School Year

CHILD'S NAME

First

Last

DATE OF BIRTH

Date

HOME ADDRESS

HOME PHONE #

PARENT 1 NAME

PARENT 2 NAME

HOME ADDRESS

HOME PHONE #

CELL #

EMAIL ADDRESS

example@example.com

EMAIL ADDRESS

example@example.com

PARENT 1 OCCUPATION

PARENT 2 OCCUPATION

Do you have a church home?

If yes, name of church

Other schools your child has attended:

Are monthly finances ever a hardship?

How did you learn of our school? (If a specific person, please enter name and address of that person)

Date

CHILD'S HEALTH RECORD: (A copy of your child's immunizations and current physical will be needed) General state of health

Doctor's name

Doctor's phone number

Are your child's immunizations up to date?(Please attach a copy of immunizations. This should include the signature of nurse or doctor who administered medications. If not, please attach medical exemption signed by doctor or notarized waiver

Are your child's immunizations up to date?

Date

Does your child have any known allergies?

Are you concerned that your child may be prone to any type of allergies? Describe

Does your child have any medical conditions which I should be made aware of?

Has your child had the following common childhood illnesses? (please circle)

Constipation Convulsions Diarrhea Fainting Spells Frequent Colds Frequent Ear Infections Frequent Sore Throats Lice Ringworm Skin Rash Soiling Stomach Upsets Urinary Problem Worms

Asthma Bronchitis Chicken Pox Diabetes Heart Disease Hepatitis Impetigo Measles Mumps German Measles Polio Scarlet Fever Tuberculosis

Does your child have any speech, hearing or visual problems?

Would there be any restrictions to play or activities?

(Last)

(First)

Birthdate

Date

By providing complete information about your child, you will be assisting staff in creating a positive experience for him/her while in care. List any information about your child's habits, abilities or personality that you feel will be helpful to the staff that cares for your child.

List any information about your child's habits, abilities or personality that you feel will be helpful to the staff that cares for your child.

Who is in the child's family?

Who lives at home with the child? Please include names and ages of siblings, if any.

What is the primary language spoken in your child's home?

Are there any special family arrangements, such as shared parenting, living in two homes, or custody specifications, etc?

Yes

No

Are there any changes or transitions that your child has recently experienced or is experiencing? (divorce, new home, death of family member, friend, or pet)

No

Additional Details?

Are there any cultural or religious practices of your family of which we should be aware?

Do you have any pets at home? If so, what are they and what are their names?

Has your child had previous preschool or daycare experience?

Additional Details? (center based, in home, with family, with parents, etc)

Please circle all of the words that best describe your child's personality and behavior: active adventurous affectionate anxious bossy bright busy calm cautious cheerful

content creative curious easily angered emotional energetic excitable friendly

gives in easily happy hesitant insecure jealous likes structure/routines loud loving

mellow outgoing prefers adult attention quiet sensitive serious shares well social

spontaneous stubborn tentative

Are there additional personality and behavior characteristics that would be useful to know about your child?

What routines/actions or items do you use to comfort your child?

What causes your child to feel angry or frustrated?

What methods do you use to respond to your child's negative behavior?

What time does your child normally go to bed at night and wake up in the morning?

What might you and/or your child be anxious about as he/she starts in this program?

What are you and/or your child excited about as he/she starts in this program?

What are some of your child's favorite play activities/interests? (This helps us in planning activities/units for classroom)

What are the top three goals you would like your child to achieve this year?

1.

3.

What other information would be helpful for the staff caring for your child to know?

LOVE ONE ANOTHER PRESCHOOL APPLICATION