Club Discovery Preschool Intake Form printable pdf download

Club Discovery

Preschool Intake Form

Child’s Name: ___________________________

Eating

Is your child on any special diet? ____Vegetarian ____vegan ____other

Does your child have any food allergies? _______ If yes, please describe _______________________________________

Sleeping

Does your child nap? _____________ How many times per day? ________________ How long? ____________________

Does your child sleep with a special blanket or toy?

Yes

Are there specific bedtime routines at home? _____________________________________________________________

Where does your child sleep at home? __________________________________________________________________

Toileting

Is your child fully potty trained?

Yes

Does your child wear pull ups at home during nap or at night?

Yes

How does your child let you know that it’s time “to go”? ____________________________________________________

Does your child need regular reminders to use the bathroom? Yes

Development

Do you have any concerns about your child’s development?

Yes

____Hearing ____Vision ____Language ____Gross Motor ____Fine Motor ____Social ____Other

__________________________________________________________________________________________________

What is your child’s primary spoken language? ____________________________________________________________

Are there other languages being used with your child_______________________________________________________

Social and Emotional development

Has your child been in child care before?

Yes

Is your child comfortable in group situations?

Yes

Is there anything we should know about your child's play with other children, by themselves, any concerns?

__________________________________________________________________________________________________

What kinds of activities does your child enjoy? Are there activities your child avoids?

__________________________________________________________________________________________________

Club Discovery Preschool Intake Form