Child Intake & Development Questionnaire
Share your child’s details, routines, and developmental needs to help us assess the best program fit.
Child Information
Child's Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian
*
Desired Start Date
*
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Month
-
Day
Year
Date
Requested Site
*
Site 1 (6 weeks–18 months)
Site 2 (18 months–2½ years)
Site 3 (3–5 years)
About Your Child
What name or nickname does your child respond to?
What are your child's favorite toys, activities, or interests?
What helps comfort your child when they are upset or having a difficult day?
Does your child have any fears, sensory sensitivities, or routines we should know about?
Development
Which best describes your child's current developmental stage?
*
Rolling
Sitting independently
Crawling
Pulling up
Walking
Running
Speaking in words/sentences
Following simple directions
Potty trained
Potty training
How does your child usually communicate their needs?
*
Crying
Gestures/Pointing
Single words
Short sentences
Full conversations
Other
If other, please describe
Is your child receiving or has your child received any developmental services?
*
No
Yes
Please explain the developmental services
Daily Care
Does your child have any allergies, dietary restrictions, or feeding concerns?
What is your child's usual nap schedule?
Are there any medical conditions or medications we should be aware of?
Social & Emotional
How does your child typically interact with other children?
*
Enjoys group play
Prefers independent play
Takes time to warm up
Other
What strategies work best when your child becomes frustrated or upset?
Additional Information
Is there anything else you would like us to know to help us determine if Jack & Jill Nursery is the right fit for your child?
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: