Club Kid Intake Form-Preschool
Child’s Name: ________________________________
Has your child been in an after school program, camp been in a child care program outside of the
2. If yes, what type of care?
3. Was your previous program a positive experience for your child?
4. How does your child feel about attending a program?
5. Describe your child’s temperament (funny, laid back, outgoing, standoffish etc)
6. What qualities are important when choosing a program?
Hours of Operation
7. What are you and your student’s goals for their time here?
8. The word “family” has different meanings for different people. Please describe what your child
considers to be their family at home. Ex: Mom & Dad, Step Parents, Single Parent, Visitation, Two
Moms, Relative Care, etc.
9. Does your child have siblings?
Name______________ Age____ Name______________ Age___ Name_______________ Age___
10. Are there any recent tragic events that you would like us to be aware of to help support your
child’s emotional needs?
Death in the family