Parent Questionnaire

Child's First Name

Child's Last Name

Please list and describe the persons or programs that have provided care for your child until now.

List the children in your family (please include names and ages).

Does your child have any DIETARY RESTRICTIONS?

Yes

No

Does your child have any special fears? (dogs, bugs, sirens, etc.)?

Yes

No

Please list your child’s likes and dislikes.

Does your child have any special hearing, vision, or other medical problems that we should be aware of?

Yes

No

Does your child have any other special concerns that we should we aware of?

Yes

No

Is your child right or left-handed?

Right

Left

Both

Not Sure

How does your child express toilet needs?

How do you deal with potty accidents?

Does your child need any assistance with dressing/undressing or with toileting/washing hands?

How would you describe your child’s personality?

What method of guidance (behavior control) do you use in your home?

Is your child receiving any special services? If so, where? (ex. speech, occupational therapy, etc.)

Is there any additional information that you feel would be beneficial to the staff?

Parent First Name

Parent Last Name

Email

***Parents-please let us know if you have any special talents, interests, skills that we would be able to use in the preschool

ALL INFORMATION SHALL BE REGARDED AND HANDLED CONFIDENTIALLY