All About My Child Form 26-27

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We look forward to your child having an enjoyable and successful Kindergarten experience. As we plan for the year ahead we would like to collect some basic background information regarding your child. This information will be used to help plan classes and identify services for the upcoming school year.

All fields are required, however if something does not apply please enter "n/a or none". This form must be completed in its entirety, it does not allow you to save and return to complete later.

Boundary school your child will attend? *

Altmayer

Dickinson

Heritage

Unknown/Open Enrolled

Child's First Name *

Child's Last Name *

Age *

Date Of Birth *

YYYY

Gender *

Male

Female

The name you would like your child to write and be called at school.

Address *

City *

State *

Zip Code *

Home Phone *

Cell Phone *

Lives With: *

Both Parents in a Single Household

One Parent

Shared Placement

Other Guardian

If Guardian other than parent, what is the relationship with the child. *

Name of Parent/Guardian 1 *

Occupation of Parent/Guardian 1

Place of Employment of Parent/Guardian 1

Work Phone of Parent/Guardian 1

Name of Parent/Guardian 2 *

Occupation of Parent/Guardian 2

Place of Employment of Parent/Guardian 2

Work Phone of Parent/Guardian 2

Siblings - List name and age of all siblings *

Child's weight at birth: *

Age child was toilet trained (list approximate age): *

Up to this time, are there any developmental delays you are aware of? (Walking, talking, vision, hearing, motor skills) Please list/explain:

Medical Background (List allergies, illnesses, hospitalizations, etc.) *

How much time do you spend reading with your child? *

Relationships with Family and Friends (List persons living in family home, playmates, outgoing vs. quiet, etc.) : *

My child attended a 4K program at: *

Pre-Kindergarten Programs or Activities (List name of Preschool, Day Care, Head Start, Early Childhood programs and how long attended, as well as child's reaction to the experience): *

Interests and Personality Traits (Include likes and dislikes, favorite people, pastimes, and favorite playtime activities) : *

Dressing Skills (Please check all attained):

zip

button

snap

tie shoes

First Day of School (Describe how you think your child will adapt (i.e. separating from you, in the classroom, with peers, etc.) :

Do you have any special concerns regarding your child?

Please list any incoming kindergarten students (cousins, neighbors, classmates (4K), life-long daycare companions) that may impact your child's behavior in a learning environment. Please include whether or not the behavior is impacted in a positive or negative way.

In my opinion my child: *

Consistently

Sometimes

Is very shy - impacts learning and friendships

Is highly active - has trouble sitting still

Can follow 2-step directions

Sticks to a project once it is started

Is able to plan and organize play activities

Sits quietly and listens to a story

Accepts discipline and limits and respects authority figures

Is able to listen and not interrupt

Cooperates willingly with peers

Is upset by changes in routine

Is easily frustrated

Cries easily

Has temper tantrums

Demands much individual adult attention

Has difficulty remembering things

Gets along well with other children

Likes to play organized games and takes turns

Can print his / her own name

Can name most alphabet letters

Can read simple sentences

Tries to write by sounding out words

Counts 1-10

Identifies Numbers 1-10