UALC Preschool and Kindergarten Child Information Form

This form must be completed for all students.

Instructions: Please complete this 2 page form in its entirety. All questions (other than volunteer opportunities) are required.

If you are presented with a question that doesn't apply to you, simply type NA (for not applicable) in the answer box so we know you saw it. Thanks!

Child's First Name *

Child's Last Name *

Birthdate (mm/dd/yyyy) *

Gender *

Class Enrolled: *

What language is spoken in your home? *

Church Affiliation *

UALC

None

Other Other

Public School District of Residence *

County of Residence *

Parent/Guardian 1 is the parent filling out the form, who will receive the confirmation email.

Parent/Guardian 1 - Full Name *

Parent/Guardian 1 - Email Address *

Parent/Guardian 1 - Contact Phone *

Parent/Guardian 2 - Full Name *

Parent/Guardian 2 - Email Address *

Parent/Guardian 2 - Contact Phone *

Help us get to know your child better

Please check all words that best describe your child's personality and behavior

All

	Yes
Active	Yes
Adventurous	Yes
Affectionate	Yes
Anxious	Yes
Bossy	Yes
Bright	Yes
Busy	Yes
Calm	Yes
Cautious	Yes

About

	Yes
Cheerful	Yes
Content	Yes
Creative	Yes
Curious	Yes
Easily-Angered	Yes
Energetic	Yes
Excitable	Yes
Friendly	Yes
Gives in Easily	Yes

Your

	Yes
Happy	Yes
Hesitant	Yes
Insecure	Yes
Jealous	Yes
Likes Structure/Routine	Yes
Loud	Yes
Loving	Yes
Mellow	Yes
Outgoing	Yes

Child

	Yes
Prefers Adult Attention	Yes
Quiet	Yes
Sensitive	Yes
Serious	Yes
Shares Well	Yes
Social	Yes
Spontaneous	Yes
Stubborn	Yes
Tentative	Yes

Does your child have any specific fears? *

Yes

No

Please describe fears: *

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Does your child have any nervous habits? *

Yes

No

Please describe nervous habits: *

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What structured activities does your child participate in? *

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What are some of your child's favorite play activities? *

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What routines/actions/words or items do you use to comfort your child? *

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List other persons living in the home and their relationship to the child (please include ages of siblings). *

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List parent and/or siblings who do not live with your child. Are there any special family arrangements, such as shared parenting, living in two homes, or custody specifications, etc.? *

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Please list any additional information about your child which would be helpful for us to know.

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Are there any cultural or religious practices of your family of which we should know (dietary restrictions, clothing, etc.)? *

Yes

No

Please explain cultural or religious practices:
*

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Are there any changes or transitions that your child has recently experienced or is experiencing (new home, divorce, death of family member, friend or pet)? *

Yes

No

Please explain changes or transitions:
*

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Has your child had a previous care arrangement (center-based, in home, with family, with parents)? *

Yes

No

Please explain previous care arrangement:
*

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Are there any foods that your child should not be fed (Child Care Licensing requires a form to be completed for children with food allergies and/or dietary restrictions)? *

Yes

No

Please explain food allergies:
*

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Do you have any concerns about your child's development? *

Yes

No

Please tell us your concerns:
*

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