Wee People Nursery School
Wee People Nursery School

 

                    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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(c) 2018 Wee People Nursery School - 2248 Walworth-Marion Road Walworth, NY 14568 - (315) 986-7246