UNIVERSAL PREKINDERGARTEN
Charlotte Avenue School
301 Charlotte Avenue
Hamburg, NY 14075
TODAY’S DATE______
STUDENT’S NAME ______Male Female
(Last Name) (First Name) (Middle Name)
DATE OF BIRTH: ______BIRTH PLACE: CITY ______STATE ______
HOME PHONE NUMBER: ______
STUDENT LIVES WITH / CUSTODY: Parents Father Mother Stepfather Stepmother Guardian Foster Parents (A court order is necessary to deny a parent access to a child.)
FATHER’S NAME/ ______
LEGAL GUARDIAN (Last) (First) (Middle Initial)
ADDRESS______CELL NUMBER______
______ZIP______
MAILING ADDRESS (If different): ______
How long have you lived at your present address______
Do you live in a HOUSE APARTMENT MOBILE HOME
MOTHER’S NAME/ ______
LEGAL GUARDIAN (Last) (First) (Middle Initial)
MOTHER’S MAIDEN NAME ______
ADDRESS______CELL NUMBER______
______ZIP______
MAILING ADDRESS (If different): ______
How long have you lived at your present address______
Do you live in a HOUSE APARTMENT MOBILE HOME
MARITAL STATUS OF PARENTS:Married Divorced Separated Single Other ______
If divorced, separated, remarried or widowed, for how long? ______
PLACE OF BUSINESS: Father’s ______BusinessPhone #______
(For emergency contact) Occupation: ______Cell Phone, etc. ______
Email Address: ______
Mother’s ______Business Phone # ______
Occupation: ______Cell Phone, etc. ______
Email Address: ______
ARE YOU NOW RECEIVING PUBLIC ASSISTANCE? Yes No If yes, please provide the Case # ______
ARE ANY OF YOUR CHILDREN RECEIVING FREE OR REDUCED LUNCH? Yes No
ARE YOU NOW QUALIFIED TO RECEIVE MEDICAID? Yes No If yes, please provide the Case # ______
ARE YOU NOW RECEIVING AID For DEPENDENT CHILDREN? Yes No If yes, please provide the Case # ______
EMERGENCY CONTACT (Other than Parent / List Relationship)
Name ______
Phone # ______Relationship ______
Name ______
Phone # ______Relationship ______
FAMILY PHYSICIAN ______Phone # ______
Has registrant ever received special education services? Yes No
NUMBER OF CHILDREN LIVING AT HOME: ______
NAME DATE OF BIRTH NAME OF SCHOOL LEVEL
______
______
______
______
______
MOTHER’S EDUCATION ______
(Highest grade completed)
MOTHER’S BIRTHPLACE______BIRTH DATE______
FATHER’S EDUCATION______(Highest grade completed)
FATHER’S BIRTHPLACE______BIRTH DATE______
PREVIOUS SCHOOL EXPERIENCE FOR THIS CHILD
Attendance on a regular basis in other Pre-K programs Yes No
(Such as Head Start, Day Care, Private Nursery School, etc.)
If YES, how many days a week ______for how long ______
Participation on a regular basis in other programs
such as Summer Recreation, Library Preschool Program, etc. Yes No
LANGUAGES SPOKEN BY CHILD: 1. ______2. ______
LANGUAGES SPOKEN BY ADULTS: 1. ______2. ______
Additional Comments: ______
______
CHILD’S HOME AND FAMILY
BIRTH:
PLEASE CHECK ONE OR MORE DESCRIPTIVE TERMS:
PARENTS:
Natural
By Adoption
Step
Foster
Other ______
If adopted or foster child, at what age did the child come to you?______
Agency involved in placement ______
Does the child know he/she is adopted? Yes No Are any of your other children adopted? Yes No
Are any of your other children foster children? Yes No
Has the child had any special preschool learning experiences, such as a language development program, etc.?
Yes ______No ______
Have any children in the family had any developmental, learning or behavioral difficulties of any kind in school? Yes No
If yes, please explain:
______
______
______
Do you suspect or has your child been diagnosed as having a handicapping condition? Yes No
If yes, please explain: ______
______
______
Are you concerned about any areas of your child’s development? ______
______
Are there any chronic, long-term illnesses in the family? Yes No
If yes, please name the person and the illness or disability: ______
______
Additional Comments Regarding Your Child’s Special Needs – Personal or Health Related: ______
______
Does your child have any allergies? Yes No
If yes, please check the appropriate box and explain:
Food ______
Medication ______
Other ______
SELF HELP:
Is bedtime Easy Difficult What time does your child go to bed at night? ______
Does your child take a nap? Yes No
What special word or words does your child use for toileting? ______
Does your child dress her/himself? Independently Needs a little help Needs a lot of help
Is he/she encouraged to take responsibility for dressing? ______
______
______
Is he/she encouraged to take responsibility for washing? ______
Has your child been examined by a dentist? Yes No If yes, when? ______
At what age did your child begin talking: one word ______sentences ______
Does your child have any nervous habits: Yes No If yes, please describe: ______
______
______
______
______
ABOUT YOUR CHILD:
Does your child prefer right or left hand? ______
Does your child answer to any special nickname? ______
Do you prefer that we use the nickname in school?______
Please describe your child’s strengths, likes, and dislikes. ______
______
______
Special interest or talents of your child ______
______
Special interest or talents of parents ______
______
What activities do you and your child carry on together? ______
______
EMOTIONS AND BEHAVIOR:
How do you discipline your child when he/she does something of which you do not approve? ______
______
______
Do both parents agree on the methods used? ______
______
How does your child respond to the above mentioned methods?______
______
______
Explain ways you help your child to do the things he does not want to do. ______
______
Has anyone other than the parents had a substantial part in the rearing of your child?
(Example: Grandparents, babysitter, child care) Yes No
If yes, please explain: ______
______
______
______
Does your child have any fears? ______
______
______
What is your child’s reaction to unfamiliar adults? ______
______
______
______
Does your child become angry or cry easily? Yes No Please explain: ______
______
______
What behaviors are most difficult for you to handle? ______
______
______
______
What ways do you feel your child takes responsibility for himself? Explain specifically. ______
______
______
______
______
PLAY AND SOCIAL SKILLS:
Does your child have a special place to play indoors and outdoors? Yes No If yes, please explain (describe areas specifically)
______
______
______
______
How long does your child play outdoors? ______
Does your child have any neighborhood playmates? Yes No
What are their ages? ______
Describe your child’s play (active, careful, loud, social, etc): ______
______
______
Does your child have any pets? ______
What are your child’s favorite play activities? ______
______
Does your child have any imaginary playmates? ______
______
READINESS SKILLS:
Does your child recognize colors: red yellow green blue others: ______
Does your child know the numbers 1 through 5? Yes No
Will your religion impose limitations upon your child’s participation in this program? ______
______
______
In what ways may we help your child in prekindergarten? ______
______
______
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