Student Information2012-2013 Academic Year

This form needs to be filled out by students entering the Early Childhood Program.

Child’s Given Name ____________________________________ Male Female

Parent’s Names _______________________________________________________________

Street Address _______________________________________________________________

City_____________________________ State__________________ Zip__________________ Primary Phone____________________ Primary Email ________________________________

Home and Family

Child’s Birth Date ____________________ Place of Birth _____________________________

Child’s Baptism Date (if baptized) __________________________________________________

Is child adopted? Yes No At what age? ___________ Does he/she know? Yes No

Father’s First Name ____________________________________________________________ Occupation _____________________________ Highest Educational Level ________________

Mother’s First Name ___________________________________________________________ Occupation _____________________________ Highest Educational Level ________________

Languages other than English spoken at home __________________________________________

Marital Status of Parents married separated divorced widowed

Please list the names and ages of siblings.

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Health and Growth

Child’s Birth Weight _________________ Delivery Normal Complications

Explain _____________________________________________________________________

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Does your child have any allergies? Yes No

Please elaborate. _______________________________________________________________ Has your child been diagnosed with any special needs? Yes No

Please elaborate. _______________________________________________________________ Any difficulty with hearing? _______________________________________________________

Any difficulty with vision? ________________________________________________________

Serious Injuries: _______________________________________________________________

Surgery: _____________________________________________________________________

Daily routine: Bedtime____________ Rises at ______________ Naps ________________

Elimination: At what age was bowel control established? __________________________________

At what age was bladder control established? ________________________________

Have any of the following been a problem for your child?

thumb-sucking eating bed wetting sleeping

elimination general nervousness

Motor Development

At about what age (in months) did your child begin to crawl? ________________________________

At about what age (in months) did your child begin to walk? ________________________________

Hand preference: Left Right No marked preference

Has your child had experience with any of the following materials?

crayons paint scissors pencils paint paste/glue markers

Play Activities

What are your child’s favorite play activities indoors and outdoors? ___________________________

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How many hours a day does your child watch TV, DVDs or tapes?____________________________

What are his/her favorite programs?_________________________________________________

Does your child enjoy children’s CDs, audiotapes? _______________________________________

What are some of his/her favorite stories and songs? _____________________________________

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How would you characterize your child’s play at home?

active boisterous quiet self-initiated energetic dependent on adults

Does your child have opportunities to play with live animals? _______________________________

List any pets found in your home: __________________________________________________

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Social Interactions

Approximately how much time does your child spend with mother each day? ____________________

Approximately how much time does your child spend with father each day? ____________________ How much time does your child spend with a caregiver/babysitter? __________________________

Does your child have playmates? Yes No How many? __________________________

The sex and age range of playmates? _________________________________________________

How does your child interact with playmates? __________________________________________

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Speech and Language Development

At about what age (in months) did your child begin to say words? ____________________________

At about what age (in months) did your child use 3-word sentences? __________________________

Describe any apparent speech difficulties: _____________________________________________

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Do you read to your child? Yes No

How often? _________________________________________________________________

What types of stories does he/she enjoy? ____________________________________________

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Emotions and Behavior

Does your child have any of the following fears?

of the dark of being alone of strangers of animals

of storms of medical personnel other___________________________

Does your child take care of personal toilet needs? put on his/her own clothing? button? zip?

How do you assess your child’s confidence? ____________________________________________

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Discipline

What points are most often at issue between you and your child? _____________________________

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What discipline techniques are used? ________________________________________________

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Life Experiences

List frequent travel experiences: ____________________________________________________

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List major or distant travel experiences: _____________________________________________

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Does your child attend Sunday School or church regularly? Yes No

What are his/her favorite Bible stories? ______________________________________________

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Additional Comments

What role do you see yourself playing in your child’s education? ___________________________

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Is there anything else we should know as we work with your child? _________________________

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What three adjectives most clearly describe your child?

1. ________________________________________________________________________ 2. ________________________________________________________________________ 3. ________________________________________________________________________

What goals do you have for your child in his/her preschool or kindergarten experience at St. James?

__________________________________________________________________________

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SIGNATURE ______________________________________________________________

DATE _________________________________

Thank you for helping us get a glimpse of your child and family.