Pleasant Lane Pre-Kindergarten Student Information Questionnaire
To assist us in becoming acquainted with your child, please complete the following questionnaire.
1. What is your child's name? (The name he/she prefers to go by)
Your answer
2. Mother's first and last name:
Your answer
3. Father's first and last name:
Your answer
4. Address:
Your answer
5. Home phone number:
Your answer
6. My child lives with...
Your answer
7. Mother's email address:
Your answer
8. Mom's cell phone (if it applies):
Your answer
9. Father's email address:
Your answer
10. Dad's cell phone (if it applies):
Your answer
11. Child's birthdate:
MM
/
DD
/
YYYY
12. Child's position in the family (birth order):
Your answer
13. Have any of the following occurred within the past year to your immediate family?
14. Did your child attend pre-school?
Your answer
15. If your child attended pre-school, for how long and where?
Your answer
16. If your child attended pre-school, were there any specific recommendations they made for kindergarten? Please be specific.
Your answer
17. Does your child take any medications? If so, for what is the medication used?
Your answer
18. Does your child appear to have any vision or hearing difficulties?
Your answer
19. Does your child have any allergies? If so, please state what they are. (Seasonal, animal, medication, etc.)
Your answer
20. Is your child left or right-handed?
21. Does your child talk freely with other adults?
Your answer
22. Does your child talk freely with other children?
Your answer
23. Please describe your child's temperament.
Your answer
24. Did your child take part in the district's pre-school screening process? If yes, were any recommendations made? What were they?
Your answer
25. Does your child enjoy looking at books?
Your answer
26. How often do you read to your child?
Your answer
27. Does your child stay interested when you read to him/her?
Your answer
28. Is your child able to remember a song or a nursery rhyme?
Your answer
29. Does your child speak/know another language? If so, what language?
Your answer
30. Has your child had any experience with crayons and scissors?
Your answer
31. Does your child look forward to coming to kindergarten?
Your answer
32. Do you have any personal or cultural beliefs that school staff should know? Please explain.
Your answer
33. Please tell us about any strengths you perceive your child to have or areas for improvement.
Your answer
34. Is there any information not yet covered which would be of benefit for the school to know?
Your answer
Thank you for filling out this questionnaire. It is our sincere hope that this information will enable us to better understand your child. Please feel free to contact us regarding anything you feel might impact your child's education. Thanks again!
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