Club Kid Intake Form-Preschool (Page 2 of 2) in pdf

11. Does your child have any allergies?

Yes

___________________________________________________________

12. Does your child have any food restrictions (personal or allergy related)?

Yes

___________________________________________________________

13. Is your child taking any medications or is there any medical information we should be aware of?

Yes

___________________________________________________________

14. Does your child have any restrictions to play or activities or any special needs we should be aware

of?

Yes

___________________________________________________________

15. What are your student’s interests and favorite activities?

At Home_______________________________________________________________

At School______________________________________________________________

16. What is your child’s primary language?

________________________________

What languages are spoken in your home? _______________________________

17. Please describe your child’s sleep habits.

Goes to bed at ________________

Wakes up at ____________ Naps at ____________

Requires security object or soother toy? Describe ______________________________

18. How does your child indicate that they need to use the bathroom (certain words or motions)

______________________________________________________________________

19. Would you be interested in volunteer opportunities or classroom visits?

Lunch with my child

Field Trip volunteer

Send supplies/treats for special occasions

Sharing an in-class activity such as game, career, cultural or family tradition activity

20. Is there any other information that you would like to share to help us better serve

your child or family?

___________________________________________________________________

Club Kid Intake Form-Preschool Page 2