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)
2. Mother's first and last name:
3. Father's first and last name:
4. Address:
5. Home phone number:
6. My child lives with...
7. Mother's email address:
8. Mom's cell phone (if it applies):
9. Father's email address:
10. Dad's cell phone (if it applies):
11. Child's birthdate:
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12. Child's position in the family (birth order):
13. Have any of the following occurred within the past year to your immediate family?
14. Did your child attend pre-school?
15. If your child attended pre-school, for how long and where?
16. If your child attended pre-school, were there any specific recommendations they made for kindergarten? Please be specific.
17. Does your child take any medications? If so, for what is the medication used?
18. Does your child appear to have any vision or hearing difficulties?
19. Does your child have any allergies? If so, please state what they are. (Seasonal, animal, medication, etc.)
20. Is your child left or right-handed?
Clear selection
21. Does your child talk freely with other adults?
22. Does your child talk freely with other children?
23. Please describe your child's temperament.
24. Did your child take part in the district's pre-school screening process? If yes, were any recommendations made? What were they?
25. Does your child enjoy looking at books?
26. How often do you read to your child?
27. Does your child stay interested when you read to him/her?
28. Is your child able to remember a song or a nursery rhyme?
29. Does your child speak/know another language? If so, what language?
30. Has your child had any experience with crayons and scissors?
31. Does your child look forward to coming to kindergarten?
32. Do you have any personal or cultural beliefs that school staff should know? Please explain.
33. Please tell us about any strengths you perceive your child to have or areas for improvement.
34. Is there any information not yet covered which would be of benefit for the school to know?
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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