INTAKE FORMHelp Us Get to Know Your Child!CHILD'S NAME(Required)Date MM slash DD slash YYYY Email(Required) What name would you like us to call your child? Nickname?(Required)Is your child fully potty trained?(Required) YES NO Does your child have any health care needs, special needs, delays, and/or disabilities? (allergies, medical condition, speech, potty training, etc.)(Required) YES NO If your child has special needs, do they have an IFSP or IEP?(Required) YES NO If yes, may we obtain a copy so that activities are individualized to address the developmental needs of your child?(Required) YES NO Has your child been in a preschool setting before?(Required) YES NO IF YES, WHERE?HOW LONG?What is the primary language spoken at home?(Required)What are some of your child’s favorite foods?Does your child have a favorite toy or comfort object? If so, what is it, and when does he/she need it most?How does your child feel about coming to school?Does your child know any other children in our center?(Required) YES NO If yes, who?What makes your child angry? How do you deal with his/her anger?Is your child especially afraid of anything?(Required) YES NO If yes, what?Does your child have any sleeping issues?(Required) YES NO What is your child’s sleeping schedule?(Required)What is your child’s sleeping schedule?NAP TIMEBEDTIME Add RemoveWhat experience has your child had with other children?(Required)How does your child show his/her feelings?(Required)What do you hope your child will gain from this school experience?(Required)What else would you like us to know about your child?(Required) Δ
