St. Paul's Episcopal Nursery School
1066 Washington Road Pittsburgh, PA 15228 412.531.2644
GENERAL INFORMATION
Child's First Name *
Your answer
Child's Last Name *
Your answer
Child's Date of Birth *
MM
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DD
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YYYY
What name should we call the child at school?
Your answer
Street Address *
Your answer
City, State, Zip Code *
Your answer
Family Email Address *
Your answer
FAMILY LIFE
Parent 1 Name
Your answer
Parent 1 Phone Number
Your answer
Parent 1 Training/Profession/Current Occupation
Your answer
Parent 2 Name
Your answer
Parent 2 Phone Number
Your answer
Parent 2 Training/Profession/Current Occupation
Your answer
Who cares for the child while parents are at work?
Your answer
Please list other children (including step-siblings) in the family - include Name/Age/Gender
Your answer
Please list other persons living in the home
Your answer
Languages, other than English, spoken in the home
Your answer
Has the family experienced illness, death, separation or divorce, significant moves, or other times of stress?
Your answer
If so, how did the child react?
Your answer
SOCIAL BEHAVIOR
Relating to others *
Always
Often
Sometimes
Rarely
Never
My child gets along with adults
My child plays easily with other children
My child finds sharing and taking turns difficult
My child is able to play alone
My child prefers to play alone
What are your child's favorite toys or activities?
Your answer
Will your child attend another nursery school, Sunday school, or group experience this year?
Your answer
What previous group experience has your child had, and what was your child's reaction?
Your answer
How do you usually discipline your child?
Your answer
What is your child's reaction to discipline?
Your answer
How does your child respond to babysitters?
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Does your child have any special fears?
Your answer
DEVELOPMENTAL HISTORY
Birth
Age of Walking
Your answer
Age of Talking - First Words
Your answer
Age of Talking - 2-3 word phrase
Your answer
Concerns regarding speech?
Your answer
Is your child toilet trained to stay dry during the day?
Approximate age?
Your answer
Does your child have bowel control?
Approximate age?
Your answer
What words does your child use when they need to use the bathroom?
Your answer
How much reminding or help do they need in toileting?
Your answer
Does your child have a good appetite?
Are there food allergies?
Does your child have good sleeping habits?
Does your child still nap/rest?
OTHER INFORMATION
Is there any other pertinent information about your family or child you would like to share with us?
Your answer
How can we help you or your child in the transition to Nursery School?
Your answer
Thank you for answering this portion of the questionnaire. We feel this information is helpful in understanding your child. In return, we assure you this questionnaire is confidential and will be used only by school staff, unless you give us specific, written permission to release this information to any other source.
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