CONCORD UNIVERSITY CHILD DEVELOPMENT CENTER
P.O.BOX 1000 D-135, ATHENS, WEST VIRGINIA24712 (304) 384-6335
PRESCHOOL ADMISSIONDATE: ______
Child’s Name ______Gender: M F
Nickname ______Birthdate ______
Home Address ______Home Phone ______
Mother’s Name ______Home Phone ______
Address ______Cell Phone ______
Employer ______Work Phone ______
E-mail address ______
Father’s Name ______Home Phone ______
Address ______Cell Phone ______
Employer ______Work Phone ______
E-mail address ______
Parent’s Marital Status:Married ____ Single ____ Widowed ____ Living together ____
Separated/Divorced ____How long? ______
Step parent ______Name ______
Custody/living arrangements ______
Siblings/Birth Dates:______
Additional household members ______
Household pets and their names ______
List persons, other than parents, who are authorized to pick up your child from the Center (I.D. is required):
NameAddressPhone
_____ permission granted for my child to be video and/or audio taped and/or photographed.
_____ permission granted to have child observed for educational purposes.
_____ permission granted for child to be assessed by professional/teachers for developmental screenings.
_____ permission granted for child to be referred, as a result of assessment, if needed.
_____ permission granted for my child to be transported for emergency medical treatment or other emergencies.
I understand that I will be notified if my child needs to be referred as a result of developmental assessments or screenings etc.
______
Parent’s SignatureDate
Child ______Luv-N-Care Questionnaire Preschool
This information is provided to your child’s teacher and will help the teacher give him/her greater attention and care.
Health
Chronic illnesses or hospitalizations: ______
Disabilities: ______
Allergies: ______
On-going medications: ______
Eating
Favorite foods ______Least favorite foods: ______
How is your child’s appetite?: ______
Social interaction:
Has child received day care services before? YesNo
How does your child interact with peers? ______
How do you comfort your child? ______
Any specific fears? ______
Sleep habits or routines______
Other information
Is your child fully potty trained?: Yes No
Does your child have any special needs? ______
Any holiday activities your child should not participate in due to religious reasons? ______
Does you child have an IEP/IFSP? ______
Does your child receive services from: ____SouthernHighlands; ___ Birth to Three; ___MercerCounty Special Ed dept.
Any information you would like the teacher to know:
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______
______
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