Child's Name_____________________________________________________________

Please answer the following questions as best you can to help the staff
get to know your child.

Experiences at School:

What school does your child attend? ______________________________________

Name of your child's teacher _____________________________________________

Describe your child's adjustment to school _______________________________

__________________________________________________________________________

__________________________________________________________________________

What kinds of grades does your child make? ______________________________

___________Good __________ Average ___________Above Average


Hobbies:

List your child's hobbies and other interests____________________________ 

_________________________________________________________________________

Experiences with Others:

What are some of the ways your child plays at home? _____________________

_________________________________________________________________________

Does your child play with neighborhood children? ________________________

If so, how? _____________________________________________________________

Does your child usually get his/her own way with other children? ________

If not, how does your child react?_______________________________________

Is the entire family together for any time during the day? ______________

_________________________________________________________________________

Has your child had any of the following experiences during the past year?

Birth of another child in the family____________ Moving _________________

Changing schools _______________ Serious illness of the child ___________

Serious illness of family member ____________ Death in family ___________

Separation or divorce of parents ____________ Other______________________

Would you describe your child as Active ___________ Quiet _______________

Friendly _______________ Shy _____________

What do you like best about your child? _________________________________

_________________________________________________________________________

_________________________________________________________________________

Is there any other information we should know about your child? _________

_________________________________________________________________________

_________________________________________________________________________

_______________________________ Parent/ Guardian Signature

_______________________________ Parent/ Guardian Signature