2019-2020 Medical and Developmental Information
Please answer all of the following questions completely and accurately. The information provided will be used solely by Good Shepherd Lutheran Preschool and will remain confidential.
Email address *
Child's First Name *
Your answer
Child's Last Name *
Your answer
Child's 2019-2020 Class *
Medical Information
Allergies *
Does your child have an allergies (especially to food and medicine)? If yes, please list below.
List Allergies
If you checked "Yes" above, please briefly list your child's allergies.
Your answer
Chronic Medical Conditions *
Does your child have any chronic medical conditions (such as diabetes, asthma, sickle cell anemia, etc.)? If yes, please list below.
List Chronic Medical Conditions
If you checked "Yes" above, please briefly list your child's chronic medical conditions.
Your answer
Medications *
Is your child on any routine medications? If yes, please list below.
List Medications
If you checked "Yes" above, please briefly list your child's routine medications.
Your answer
Premature Birth *
Was your child born prematurely?
Weeks Premature
If you checked "Yes" above, please select the option that best describes your child.
Hospitalizations *
Has your child had surgery or been hospitalized for more than 24 hours? If yes, please describe below.
Describe Hospitalizations
If you checked "Yes" above, please briefly describe your child's hospitalizations.
Your answer
Vision or Hearing Issues *
Have you noticed any vision or hearing problems? If yes, please describe below.
Describe Vision or Hearing Issues
If you checked "Yes" above, please briefly describe your child's vision or hearing problems.
Your answer
Other Medical Issues *
Are there other medical circumstances the Preschool should know about your child? If yes, please describe below.
Describe Other Medical Issues
If you checked "Yes" above, please briefly describe your child's other medical circumstances.
Your answer
Screenings and Services
IEP or IFSP *
Does your child have an Individualized Education Program (IEP) or an Individualized Family Service Plan (IFSP)?
IEP or IFSP Accommodations
If your child has an IEP or IFSP, please summarize any accommodations necessary for your child while in school.
Your answer
Share IEP or IFSP
If your child has an IEP or IFSP, are you willing to share a copy of it with GSLP so that your child's teachers may use it to plan accommodations in the classroom?
Developmental Screenings *
Has Child Find, Infants and Toddlers, or an other screening agency (speech, occupational therapy, etc.) evaluated your child? If yes, please describe below.
Describe Screenings
If you checked "Yes" above, please describe any screenings your child has had.
Your answer
Disabilities *
Does your child have any diagnosed learning or other disabilities? If yes, please describe below.
Describe Disabilities
If you checked "Yes" above, please describe any disabilities your child has had diagnosed.
Your answer
Services Received
Please indicate which, if any, of the following services your child has received:
Describe Services
If you checked any services above, please describe, in detail, the services received (age begun, frequency, diagnosis, etc.).
Your answer
Other Developmental Concerns *
Do you have concerns about your child's development (behavior, language, speech, coordination, etc.)? If yes, please describe below.
Describe Other Developmental Concerns
If you checked "Yes" above, please describe any other concerns you have about your child's development.
Your answer
Electronic Signature *
Type your full name below to sign this form.
Your answer
Today's Date *
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A copy of your responses will be emailed to the address you provided.
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