Special Needs Preschool Application
Thank you for your interest in the Canal Winchester Preschool Program. Please complete this form and click the submit button at the bottom to apply for our program. If you have any questions, please contact Maleea Anderson, Preschool Coordinator, 614-920-2757. Completing this form will help the District collect necessary information. Following the completion of this form, the Preschool Coordinator will contact you to schedule an appointment time to meet and discuss your concerns. Thank you!
Email address *
Date:
MM
/
DD
/
YYYY
Form completed by:
Your answer
Relationship to child:
Your answer
Child's First Name *
Your answer
Child's Last Name *
Your answer
Nickname:
Your answer
Child is
Child's Date of Birth (mm/dd/yyyy) *
Your child must be 4 years old to be considered for the Peer Model Program.
Your answer
Address *
You and your child must reside within the Canal Winchester Local School District
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Mother/Guardian's Name *
Your answer
Home Phone Number
Your answer
Cell Phone Number *
Your answer
Email Address *
Your answer
Father/Guardian's Name *
Your answer
Home Phone Number
Your answer
Cell Phone Number *
Your answer
Email Address *
Your answer
Describe the home environment including those living in the home (siblings, other family members).
Your answer
Describe any unique family circumstances that have a significant impact on this child's development.
Your answer
Pregnancy Information. Please check any of the following complications that occurred during pregnancy.
Length of Pregnancy weeks:
Your answer
Child's Birth Weight (lbs., oz.)
Your answer
Check any of the following complications that occurred during birth:
List any medical conditions treated by a physician.
Your answer
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 had a head injury? Explain.
Your answer
Current Medications:
Your answer
Has your child ever participated in therapy (speech-language, occupational, physical, counseling, etc.)?
If your child has participated in therapy, please describe the type of therapy, frequency, and duration of the therapy sessions.
Your answer
Describe any hospitalizations or surgeries your child has had.
Your answer
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
Showed an interest in or attraction to sound
Understood first words
Spoke first words
Walked up stairs
Is your child fully toilet trained?
Do you suspect any problems with your child's development? *
Presenting problem - Check the area(s) which are of concern:
Describe things that have been done (interventions) to address the concerns.
Your answer
Please complete the section below by marking check all that apply. *
Required
Which describes your child now? Please check all that apply.
Which of the following did your child attend?
Which are your child's current skill strengths? Check all that apply.
Which are your child's current skill weaknesses? Check all that apply.
Primary language spoken by the child: *
Your answer
Primary language spoken in the home
Your answer
How does your child relate to others? Please check all that apply.
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?
Any additional information that may be useful.
Your answer
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.
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.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Canal Winchester Schools. Report Abuse - Terms of Service