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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