Special Needs Preschool Application
Thank you for your interest in the Canal Winchester Preschool Program. Please complete this form if you have concerns with your child's development. When finished, please be sure to click the submit button at the bottom of the application. This application will be time stamped.  

If you have any questions, please contact Maleea Anderson, Preschool Coordinator, at 614-920-2757.  

Completing this form will help the District collect necessary information in order to appropriately address your concerns. Following the completion of this form, the Preschool Coordinator will contact you to schedule an appointment to discuss your concerns further and to share the next steps in the process.  Thank you!
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Email *
Application Date: *
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Child's First and Last Name *
Child's Date of Birth (mm/dd/yyyy)                               *
Child MUST be at least 3 years old to be considered for the evaluation process.
Age of child: (MUST be 3 years old at the time of completing this application to be considered for the evaluation process.) *
Do you suspect any problems with your child's development? *
Form completed by: *
Relationship to child: *
What name does your child respond to? Nickname: (if the child goes by a different name) *
Child is *
Primary language spoken by the child: *
Primary language spoken in the home *
What language do adults use to communicate to each other in the home?
What language does the child primarily speak in when communicating to others?
Address *
You and your child must reside within the Canal Winchester Local School District
City *
State *
Zipcode *
Mother/Guardian's Name *
Home Phone Number *
Cell Phone Number *
Email Address *
Father/Guardian's Name *
Home Phone Number *
Cell Phone Number *
Email Address *
Describe the home environment including those living in the home (siblings, other family members). *
Describe any unique family circumstances that have a significant impact on this child's development. Please also include foster care or guardianship information if applicable. *
Birth and Medical History
Please answer the following questions so we can learn more about your child.
Pregnancy Information. Please check any of the following complications that occurred during pregnancy. *
Required
Length of Pregnancy weeks: *
Child's Birth Weight (lbs., oz.) *
Has your child participated in well checks? If so, has your doctor presented any concerns for your child’s development? *
List any medical conditions treated by a physician. *
Check any of the following complications that occurred during birth: *
Required
Developmental Information - Did your child achieve the following milestones within the appropriate age level? *
Yes
No
Turned Over
Sat alone
Crawled
Stood alone
Walked alone
Walked down stairs
Walked up stairs
Spoke first words
Showed an interest in or attraction towards an image, toy, or person
List any prescribed medications your child takes regularly (if applicable)
Hearing Questions *
Yes
No
Frequent ear infections
Tubes
Hearing problems
Sensitive to certain sounds
Vision Questions *
Yes
No
Vision problems
Wears glasses
Sensitive to certain lights or colors
Has your child ever experienced surgeries or been hospitalized? If so, please describe. If no, then please say No or Not Applicable. *
Educational History and Prior Experiences
Has your child ever participated in any of the following:   *
Required
Does your child currently participate in therapy? If so, please describe the type of therapy, frequency, and duration of the therapy sessions. If no, then please say No or Not Applicable. *
Which of the following did your child attend? *
Required
If you selected a program from the above question, please provide the name of the program, dates the child attended, and the frequency of your child's attendance. Otherwise please respond "not applicable". *
Has your child been asked to leave or been removed from a program due to behavior? *
Due to the COVID pandemic, what opportunities has your child had around other same-age peers? *
At what age did your child speak their first words? *
At what age did your child begin to combine words together (e.g. book please)? *
Please select where your child is at in the potty training process *
Can your child independently wash and dry their hands? *
Presenting problem - Check the area(s) which are of concern: *
Required
Describe things that have been done (interventions) to address the concerns. If none, then please say none. *
When my child communicates, they most commonly use: *
My child can: (check all that apply) *
Required
My child can follow directions that are: *
Please complete the section below by checking all that apply. *
Required
Which are your child's current strengths?  Check all that apply. *
Required
Which are your child's current weaknesses?  Check all that apply. *
Required
How does your child relate to others?  Please check all that apply. *
Required
When playing with friends, how does your child participate.  Please check all that apply. *
Required
Has your child experienced any of the following stressful events during the past year? *
Required
Any additional information that may be useful.
Please select your preference for preschool *
Should your child be accepted into the preschool program, we will do our best to accommodate.  However, it is not guaranteed.  
Please select your preference for meetings *
Kindergarten Start Date *
Please indicate the year you anticipate your child to start kindergarten.  Please be aware that children must be age 5 by August 1st in order to start kindergarten.
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