What Makes My Child Special
What Makes My Child Special
Child’s Name: __________________________________ Name my child goes by: __________________________
Birthday______________
Previously, my child was cared for _____ in a Home Day Care setting _____ At another Center
_____ At Home with Me _____ By a Relative, Friend or Neighbor
There were __________ other children around my child most of the day.
I would say that his/her day was relatively structured/unstructured. (circle one)
In new situations my child tends to: ________________________________________________________________
Any allergies or special needs: ____________________________________________________________________
Is the child potty trained? _______ What does your child say when he/she wishes to use the toilet? ______________
Does your child need help: Dressing/Undressing_____ Eating_____ Washing Hands_____ Toileting_____
Does your child have any special fears or problems? ___________________________________________________
Health
Has your child has a health exam or health / developmental screening in the past year? ______
If yes please indicate normal or abnormal results and any necessary follow-up documentation that we might need to be aware of. Normal ___ Abnormal____ Comments:_________________________________________________________________________________________________________________________________________________________________________________
Sleep
My child generally does/does not take ________ nap(s) during the day. They each last around ________ hours.
Special sleep items (doll, blanket, etc.): _____________________________________________________________
Special hints to help at nap time: __________________________________________________________________
Eating
My child has special dietary needs (please list): _______________________________________________________
My child has food allergies to: ____________________________________________________________________
Special hints/concerns regarding mealtime: __________________________________________________________
Family Practices
Child rearing practices: ________________________________________________________________________________
Family values and beliefs: _______________________________________________________________________
Family likes to do the following activities: ________________________________________________________________
Family cultural practices: ____________________________________________________
Other
Does your child have any friends/acquaintances at this Center? (circle one) Yes No
If yes, who are they? _____________________________________________________________________
I could describe my child as (shy, outgoing, a leader, strong willed, etc.): __________________________________
Any other information that would help us best meet your and your child’s needs? ____________________________
_____________________________________________________________________________________________
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