REGISTRATION FORM 2003-2004 - Temple B'nai Jeshurun

REGISTRATION FORM 2011-2012
The Rabbi Barry H. Greene Early Childhood Center
CONGREGATION B’NAI JESHURUN
TODDLERS • PLAYSCHOOL • PRESCHOOL • KINDERGARTEN •
1025 South Orange Avenue • Short Hills • New Jersey • 07078
(This information will be kept strictly confidential)
GENERAL INFORMATION:
CHILD:
Full Name:
(First and LAST)
Age as of Sept. 30 th of this year:
Date of Birth:
Nickname, if any:
Currently enrolled in the following Early Childhood Program:
Home Address:
Home Phone:
e-mail Address:
PARENT 1:
Full name:
Home Address (if different):
Home Phone:
Cell Phone:
Occupation:
Employer:
Business Address:
Business Phone:
e-mail Address:
PARENT 2:
Full name:
Home Address (if different):
Home Phone:
Cell Phone:
Occupation:
Employer:
Business Address:
Business Phone:
e-mail Address:
If part-time, please list your business hours and days:
CONGREGATION B’NAI JESHURUN EARLY CHILDHOOD REGISTRATION FORM
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FAMILY INFORMATION:
Are You a Temple Member? Yes No
If not, what is the family's synagogue affiliation?._______________________________________
What is the name of the family's rabbi?______________________________________________
Are both parents living? Yes No
Is your child adopted? Yes No
Is your family a step-family? Yes No
Parents are living together divorced separated both Jewish
What language is spoken in the home other than English? _____________________________
Who else lives in your household?
Brothers? Names: ___________________________________ Ages: ________________
Sisters? Names: ___________________________________ Ages:________________
Others? Names: ___________________________________ Relation: _____________
Does anyone else assume occasional responsibility for care of child?______________________
By what name is this person known to your child? _____________________________________
MEDICAL INFORMATION:
The name of my child's physician is: __________________________________________________
The phone number of my child's physician is:___________________________________________
Is your child currently under continuing medical treatment? Yes No
If so, please explain _______________________________________________________________
_______________________________________________________________________________
MEDICATIONS:
What medications does your child take on a regular basis? _______________________
______________________________________________________________________
What is the dosage? _____________________________________________________
What impact, if any, will this medication have on your child's progress in school?
________________________________________________________________________
_______________________________________________________________________
ALLERGIES:
(If you respond 'yes" to any of these, please complete *Allergy/Sensitivity" form which is enclosed)
Is your child allergic or sensitive to any foods? yes no
Is your child allergic or sensitive to insect stings or bites? yes no
Is your child allergic or sensitive to any medication? yes no
Is your child allergic or sensitive to anything else? yes no
CONGREGATION B’NAI JESHURUN EARLY CHILDHOOD REGISTRATION FORM
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DEVELOPMENTAL:
Has your child had a history of ear infections? yes no
Does your child have a hearing loss? yes no
Has your child had a history of respiratory infections? yes no
Does your child speak clearly? yes no
Does your child stutter? yes no
Does your child speak "baby talk? yes no
Does your child have a speech delay? yes no
Has your child ever received any of the following special services?
Speech OT PT Other
If so, please explain __________________________________________________________________________________
_____________________________________________________________________________________________________
PHYSICAL HISTORY:
What physical conditions might limit your child's participation in school? ___________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What serious diseases has your child had? _________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please list any operations your child has had:
OPERATION DATE OUTCOME
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
PERSONAL/SOCIAL INFORMATION:
BEHAVIOR:
Is there anything you would like us to know about your child's behavior, habits or activities? __________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
How do you regulate your child's behavior? ________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
CONGREGATION B’NAI JESHURUN EARLY CHILDHOOD REGISTRATION FORM
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SEPARATION:
Who will accompany your child to school (please circle):
parent carpool other_____________________________________________
Do you expect a separation problem? yes no
Is your child used to being with adults other than parents? yes no
How does your child act when left by parents? ____________________________________
__________________________________________________________________________
________________________________________________________________________________________
SLEEP PATTERNS:
Does your chili still nap? regularly sometimes rarely
What is your child's bedtime? ______________
Does your child sleep through the night? usually sometimes rarely
SOCIALIZATION:
Does your child have a room of his/her own? yes no
Is your child used to having playmates? yes no
Where does your child play? indoors outdoors
How do you think your child relates to other children?______________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
What are the ages and sex of two children with whom your child has played regularly during the past year?
________________________________________________________________________________________
Has your child attended any early childhood programs?
At B'nai Jeshurun: Baby Talk Playtime For Friends Shabbat Shalom Club Playschool
Other Schools? Location? _________________________________________________________________
Other Play Groups? _______________________________________________________________________
What other group experiences has your child had?
Dancing School yes no Dramatics yes no
Gymnastics yes no Other:_______________________________
TOILET TRAINING:
Is your child toilet trained? yes no
How does your child let it be known that (s)he needs to go to the bathroom? ___________________________
________________________________________________________________________________________
What bathroom words does your child use? _____________________________________________________
________________________________________________________________________________________
CONGREGATION B’NAI JESHURUN EARLY CHILDHOOD REGISTRATION FORM
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MISCELLANEOUS:
Has your child exhibited a "handed" preference? yes no right left
Does your child have any fears you are aware of? ________________________________________
________________________________________________________________________________
________________________________________________________________________________
What are your child's favorite activities?________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Does your child do any of the following? (please circle)
nail-biting thumb sucking tantrums biting
What special concerns do you have in terms of your child?_________________________________
________________________________________________________________________________
________________________________________________________________________________
List any other information that will aid us in working more effectively with your child:______________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PARENTAL SIGNATURE
After fully completing this registration form, please sign, date, and return it to the Early Childhood Office
as soon as possible. Please include a recent photo of your child with the form.
Signed:__________________________________________
__________________________________________
Date: ____________________________________
CONGREGATION B’NAI JESHURUN EARLY CHILDHOOD REGISTRATION FORM
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