Early Learning Center Interest Form

Early Learning Center Interest Form
This form is to help us gauge how best to help you and your child; Please answer the questions below.
Parent Full Name*
Parent Phone Number*
Parent Email*
Child Full Name*
Date Of Birth Of Child*

MonthDayYear
Date
Start Date Preferred*
Type of care needed:*

Infants (6 weeks to 1 AND walking)Toddler (1 AND walking to 2 1/2)Pre-School (2 1/2 to school age)
Staff Who Took Inquiry (If Applicable)
Questionnaire

Please answer to the best of your ability
Hours your child will be at the center:
Children and Adults living in the home; Name/Age/Relationship to the child:
Describe your home routine for the child:
Does your child have an IEP Plan?

YesNo
Please describe the IEP/Any special requirements needed for your child:
Name a few things your child excels at:
What goals would you like your child to have while in care?

Please Answer The Following Situations:

Rows	Not Yet	Sometimes	Most Of The Time	Often
Your Child Takes A Nap
Your Child Undresses/Dresses Themselves To Potty
Your Child Forms Words Clearly ex. Potty, Hug
Your Child Participates In Independent Play
Your Child Participates In Group Play
Your Child Plays With Other Children Well
Your Child Handles Your Absence Well
Your Child Likes The Idea Of School
Your Child Recognizes Their Name Being Said
Your Child Knows Basic Colors And Letters
Your Child Reads To You
You Read To Your Child
Your Child Reads By Themself

Are there any accommodations needed for medical or religious beliefs?
Any changes in the home that could affect your child, that we need to help support?
Any topics you would like to talk to the Director about:
Should be Empty:

Questionnaire