intake by dandanhuanghuang

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									  CHARLIE BROWN PRESCHOOL & CHILDCARE


                                                Intake Sheet

    I.          Child’s Identification Information

         Name:                                                                     Nickname:


         Address:                                                                  Phone:


         Sex:                                                   Birthdate:



    II.         Family Information: Parents or Guardians

Name                         Address           Place of Employment                    Work Phone

______________________________________________________________________

______________________________________________________________________

___Single            ___Married        ___Divorced       ___Seperated        ___Foster Parent ___Deceased

Names and Birthdates of other children in the home:

_______________________________                          _____________________________
_______________________________                          _____________________________
_______________________________                          _____________________________


    III.        Child’s Medical History

* Allergies (goods, medications, bees, etc.)____________________________________________________

* Chronic or recurrent illnesses or diseases(asthma, seizures, diabetes, etc.) _______________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________
         (Please write “NONE” if your child has no medical problems)

                        Does your child take medication for this condition? ____Yes ___No
                 If yes, please state the name and dosage__________________________________
                 Will the medication need to be given during program hours? _____Yes _____No
             If yes, when and how is it to be given ?________________________________________
     What should we do if your child has a problem related to her/his medical conditions during program hours?
            ________________________________________________________________________

                ________________________________________________________________________

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IV.       Play and Sociability

*     How does your child get along with other children?______________________________________________

__________________________________________________________________________________

His/Her usual playmates are ___girls ___boys ___older ___younger ___none

*     What is the usual size of your child’s neighborhood playgroup? ___________________________

* Previous group experiences other than school:___Preschool ___Playgroup ___Other(specify)
__________________________________________________________________________________

V.        Personality and Emotional Development

*     Does she/he accept new people easily? ___Yes ___No

*     What are your child’s fears? _______________________________________________________

*     Is your child usually happy? ___Yes ___No

*     What nervous habits does you child have? ____________________________________________

VI.       Other Information

*     Does your child have any unusual eating problems or food dislikes? (Explain)

__________________________________________________________________________________

__________________________________________________________________________________

* What is your child’s usual bedtime?________________ usual waking time?__________________
* What is your child’s attitude toward taking a nap?_______________________________________
__________________________________________________________________________________


                                                  Urination                 Bowel Movement

*How does he/she state need?__________________________________________________________

*How dependable is he/she?___________________________________________________________

*Do you consider your child to be

Right-handed___________                  Left-handed_____________           Not sure_____________

*Give any further information that would be helpful in understanding your child or would enhance
your child’s experience in our program. _________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

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