After School Program Developmental History Form printable pdf download

After School Program Developmental History Form

AFTER SCHOOL PROGRAM

DEVELOPMENTAL HISTORY FORM

Child’s Name________________________________Date of Birth________________

Language spoken at home?

Any speech difficulties?

Special physical conditions, disabilities?

Allergies i.e. asthma, hay fever, insect bites, food reactions?

Serious illnesses and/or hospitalizations?

Regular medications?

Social Relationships

How would you describe your child?

Previous experience with other children/day care?

Ability to play alone?

Favorite activities/sports?

How do you comfort your child?

What is the method of behavior management/discipline at home?

What would you like your child to gain from after school?

Is your child receiving any extra help duing the school day or outside of school i.e. PT OT speech tutoring?

Is there anything that you think would help us understand your child better i.e. divorce, death in family, addition of new family

member

Parent signature________________________________________________Date___________

Please feel free to use the other side of this page.

After School Program Developmental History Form