Preeschool interest form

Child Information

Does your child have any daycare, preschool, or class experience? If so, please list and describe Who provides your child with their daily care? (ex: parent, nanny, relative, specific daycare/preschool, etc.) Does your child have allergies? If yes, please elaborate. Describe your child’s personality and current interests. Please elaborate and be as detailed as possible. Describe your child’s level of independence at home. (ex: gets dressed, puts shoes on, clears dishes, eats independently, cleans up toys, plays independently, etc.) How long is your child able to focus and engage on age appropriate tasks/activities? (ex: legos, puzzles, drawing, painting, gardening, etc.) Describe your child’s developmental strengths and challenges. Please elaborate and be as detailed as possible. (ex: consider social interactions, temperament, separation from caregivers, language/communication, milestones, etc.) How does your child show frustration/anger? Please elaborate and be as detailed as possible. Describe your child’s level of independence at home. (ex: gets dressed, puts shoes on, clears dishes, eats independently, cleans up toys, plays independently, etc.) How does your child react to you leaving them? How many hours per day (on average) does your child watch tv? What type of shows/movies? Does your child use a tablet or phone? If so, how many hours per day (on average)? What does your child do on it? Does your child play video games? If so, how many hours per day (on average)? What type of games? Do you have any concerns about your child’s development? Please elaborate and be as detailed as possible. What are your goals for your child's development? Please elaborate and be as detailed as possible. Has your child had a formal developmental evaluation and/or do they receive services privately or through early intervention? Is there anything else you would like us to know about your child that would help us understand him/her better?

Family Information

Please list all family members living at home and their relationship to your child. Please include the current schools and ages of siblings. Please list all languages spoken in your home and your child’s level of proficiency in each. How do you and your family spend time together? What type of activities do you enjoy together as a family?

Contact Information

Parent/ Guardian 1 Full Name

Parent/ Guardian 2 Full Name