Jefferson Park Parent Intake Form 2018-2019

Child Name *
Child Name
Birth date *
Birth date
Gender *
Parent or Guardian One
Name *
Name
Address
Address
Phone Number *
Phone Number
Parent or Guardian Two
Name 2
Name 2
Address 1
Address 1
Phone 1
Phone 1
Family History
Marital Status
Please list other children in your home, names and ages
Play & Social Skills
This area is to help us understand your childn's interaction with other children.
Previous play group experience
Personality & Emotional Development
Select as many as are applicable
List names below
Diet
Is your child on a special diet? *
If none type n/a
Sleeping
Toileting
Development
Which areas?
Social & Emotional Development
Behavior & Coping
Pick Up List
The following people are authorized to pick up from preschool.
Name 3
Name 3
Phone 2
Phone 2
Name 4
Name 4
Phone 3
Phone 3
Name 5
Name 5
Phone 4
Phone 4
Name 6
Name 6
Phone 5
Phone 5