Callahan School Inclusion Preschool Program
This is the application to apply for a screening to participate in the inclusion preschool program. Upon completion of this form, you will be contacted regarding scheduling the required screening.
What is your child's name? *
What is your child's date of birth? *
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Age of your child as of September 1, 2021. *
Current Address *
City *
State *
Zip Code *
Mother's Name
Mother's Employer
Phone Number *
E-Mail Address
Father's Name
Father's Employer
Phone Number
Child currently lives with *
Has your child previously attended a preschool program? *
Reason for leaving preschool program.
Does your child currently receive speech therapy, occupational therapy, or physical therapy? *
Has your child ever received early intervention services? *
Communication Development
Please answer the following questions.
Does your child understand and follow directions? *
Does your child express wants and needs? *
Does your child use two to five word phrases? *
Does your child engage in conversations with peers/adults?
Clear selection
Adaptive Behavior/Daily Living Skills
Please answer the following questions.
Does your child toilet independently? *
Does your child wash and dry hands without assistance? *
Does your child follow mealtime routines? *
Does your child eat with a spoon/fork? *
Does your child open a food or drink container? *
Social/Emotional Development
Please answer the following questions.
Does your child participate in pretend play? *
Does your child initiate play with others? *
Does your child express positive and negative emotions in socially appropriate ways? *
Does your child accept limits? *
Does your child separate easily from his/her family? *
Does your child share and take turns peers? *
Does your child understand how actions affect others and begin to accept consequences of behavior?
Clear selection
Cognitive Development
Please answer the following questions.
Does your child count 1-10? *
Does your child point to or name shapes? *
Does your child match and sort objects by specific characteristics (i.e. color, shape, size)? *
Does your child state whether he/she is a boy or girl? *
Does your child point to or name body parts? *
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