Please enable JavaScript in your browser to complete this form.Child's Name *FirstLastNickname/Name your child goes byChild's Date of Birth *Were pregnancy and delivery normal? *YesNoIf no, please explain.Please list any allergies or dietary restrictions that your child has. *Please describe any health or behavior difficulties that we need to be aware of. *Has your child had a hearing test? *YesNoHas your child had recurrent ear infections? *YesNoHas your child had a vision test? *YesNoDoes your child wear glasses? *YesNoHas your child been referred for evaluation in any of the following areas? (Please check all that apply) *Fine MotorGross MotorSpeechLanguageBehavioral HealthNone of the aboveIs your child currently receiving services in any of the above areas? (i.e. Speech Therapy) If so, please describe the services they are receiving. *What is the primary language spoken in your home? *Please list all members of your household. Please include name/birthdate/relationship to child. *Do parents live together? *YesNoIf parents are divorced/living apart, are there any custodial arrangements we should be aware of? *YesNoIf yes, please explainIs this your child's first preschool experience? *YesNoHas your child had experiences playing with other children? *YesNoIf yes, what kinds and with what age range of playmates?Tell us about your child's personality. *Does your child have any specific fears? If yes, please explain. *What makes your child angry/frustrated? *How do you handle unacceptable behavior at home? *What are some of your child's favorite play activities? *Do you have any concerns about your child's development or their ability to adjust to this program? *Please provide any additional information that will help us in caring for your child.Parent/Guardian Name *FirstLastToday's DateSubmit