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Procare App Android
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Payroll App Iphone
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Education
Blog
History
Visit Us
Parents
Enrollment
Product Recalls
Parent Intake Form
Procare App iPhone
Procare App Android
For Staff
Time Off Request
Staff Email
Payroll App Android
Payroll App Iphone
Work Request
Donate
Parents
Enrollment
Product Recalls
Parent Intake Form
Procare App iPhone
Procare App Android
Jefferson Park Parent Intake Form
Child Name
*
First Name
Last Name
Birth date
*
MM
DD
YYYY
Gender
*
Male
Femail
Parent or Guardian One
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Place of employment
Phone Number
*
(###)
###
####
Parent or Guardian Two
Name 2
First Name
Last Name
Address 1
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Place of employment
Phone 1
(###)
###
####
Family History
Marital Status
Single
Married
Divorced
Separated
Widow/Widower
Other children in home
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.
Does your child get along with other children?
Yes
No
The gender of most of your child's playmates?
Male
Female
Other
Are your child's playmates older or younger?
Older
Younger
Previous play group experience
Preschool
Play Group
Church Group
Personality & Emotional Development
Is your child affectionate
Yes
NO
Who is your child affectionate toward?
Does your child accept new people easily?
Yes
No
What does your child fear?
What is your child's temperament?
What nervous habits does your child have?
Child Is living with
*
Select as many as are applicable
Both Parent & Siblings
Mother
Father
Legal Guardian
Relatives
Other
If parents are no longer together please indicate where there are step parents or significant others
List names below
Is you child adopted? What was the adoption age?
When it comes to discipline, which parent usually does this and how?
Give any further information you believe will be helpful to understanding your child.
Diet
Is your child on a special diet?
*
Vegetarian
Vegan
Pescatarian
ovo-lacto
other
List any food allergies
*
If none type n/a
Does your child use
Bottle
Sipply cup
Regular Cup
Nursing
Other
How often does your child eat?
3 x per day
4 x per day
5 +
Sleeping
Does your child nap?
Yes
No
Your Child's Bed Time
*
How does your child feel about nap time or bed time?
*
How many times per day?
Toileting
Does your child use diapers?
*
Yes
No
Does your child use potty or toilet?
Does your child let you know when it's time to go?
Yes
No
Does your child need regular reminders to use the bathroom?
*
Yes
No
Development
Do you have any concerns about your child's development?
Yes
No
Which areas?
Hearing
Vision
Language
Gross Moto
Fine Moto
Social
Other
What is the primary language spoken?
Are there any other languages used with your child?
Social & Emotional Development
Has your child been in child care before?
Yes
No
Is your child comfortable in group situations?
Yes
No
What is your child's routine at home?
Is there anything we should know about your child's play with other child or themselves?
What activities does your child enjoy?
What activities does your child avoid?
Does your family have any pets?
Behavior & Coping
What soothes your child?
What frightens your child?
Does your child have a favorite song or game?
What are your expectations or hops for you child at school?
What are your expectations of the staff?
Is there anything else about your family or child you would like to share?
Pick Up List
The following people are authorized to pick up from preschool.
Name 3
First Name
Last Name
Phone 2
(###)
###
####
Name 4
First Name
Last Name
Phone 3
(###)
###
####
Name 5
First Name
Last Name
Phone 4
(###)
###
####
Name 6
First Name
Last Name
Phone 5
(###)
###
####
Before and Aftercare Program
*
Yes
No
Thank you!
