Club Kid Intake Form-Preschool printable pdf download

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

home?

Yes

2. If yes, what type of care?

Center

In-Home

Family Member

Seasonal Camp

3. Was your previous program a positive experience for your child?

Yes

Neutral

4. How does your child feel about attending a program?

Positive

Negative

Neutral

5. Describe your child’s temperament (funny, laid back, outgoing, standoffish etc)

___________________________________________________________________

6. What qualities are important when choosing a program?

Price

Location

Activity Level

Cleanliness

Teacher Relationship

Hours of Operation

Activity Options

Other ____________________

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?

Divorce

Death in the family

Moving

Other

____________________________

Club Kid Intake Form-Preschool