 Child’s Information Sheet
Full name of child_______________________________________ Nickname_____________
Date of birth__________________________________ Sex ____________________________
Home Address_________________________________________________________________
Town________________________________________________Zip_____________________
Phone______________________________ Cell phone/Pager___________________________
Email address__________________________________________________________________
Full name of mother____________________________________________________________
Occupation___________________________ Work Phone_________________________
Full name of father_____________________________________________________________
Occupation___________________________ Work Phone_________________________
Brother(s) and sister(s) name__________________________________ Age _______________
_________________________________________________________ Age _______________
_________________________________________________________ Age _______________
What school district will your child be attending? _____________________________________
In what year will he/she start kindergarten? __________________________________________
Are you considering giving your child an extra year?___________________________________
Person(s) to call in case of an emergency, if parent is not home:
1. ______________________________________________ Phone #_____________________
2. ______________________________________________ Phone#_____________________
Family Physician__________________________________ Phone #_____________________
Dentist__________________________________________ Phone #_____________________
Please specify any pertinent medical information we should be aware of:____________________
______________________________________________________________________________
Are there any foods your child is allergic to? __________________________________________
Is your child toilet trained or in the process of being trained? ______________________________
Is your child: right handed_____________left handed______________ both________________
Will this be your child’s first experience away from home? _______________________________
Will your child sit and listen to a story?_______________________________________________
Do you have any concerns regarding your child’s speech/articulation?_______________________
Do you have any concerns with your child’s fine motor skills ie: grip, coloring, cutting__________
_______________________________________________________________________________
Has your child had any play experiences with his/her peers?_______________________________
Is your child able to separate from you?_______________________________________________
Has your child attended any other nursery school or daycare program? ______________________
If yes, what program did they attend? _________________________________________________
Has your child ever been evaluated through the “Early Intervention” program and/or a preschool agency?_________________________________________________________________________
Has your child ever received itinerant services for speech, special ed, OT or PT? _______________
What do you expect your child to gain from his/her nursery school? _________________________
________________________________________________________________________________
Would you like your name & phone number on a class list? Yes_______ No_______
Would you be willing to drive for our field trips? Yes_______ No_______
Additional information about your child_________________________________________________
Mail completed form back with your Program Registration Form.
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