child's play tell us about your child - Child's Play Learning Center

CHILD’S PLAY LEARNING CENTER

1530 Norwalk

Katy, TX 77450

281-578-9332

ENROLLMENT INFORMATION

OFFICE USE ONLY

CODE#:____________

CLASS:____________

**Please include a CURRENT photo

of your child with these forms.** DAYS:_____________

4 YEARS OLD

DATE OF APPLICATION:______________

DATE OF ADMISSION:________________

HOURS: 9:10AM TO 2:10PM

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Registering for: Monday/Tuesday/Wednesday/Thursday:______

Monday/Wednesday/Thursday:_____________

Fun Friday (9:00am to 12:00am):___________

Spanish Class (2:10 to 3:15): Monday:_____ OR Thursday:______

Child’s Full Name:________________________________ Nickname:________________________

Child’s age as of 9/1/12:___________________________ Sex:_____________________________

Date of Birth: Month:__________ Day:__________ Year:__________

Child’s Home Address:______________________________________________________________

City:________________________________ Zip Code:___________________________________

Sub-division:______________________________________________________________________

Home Phone: ________________________ Cell Phone:__________________________________

E-mail:___________________________________________________________________________

Are you a registered member of Epiphany?:____________

Previous School Attendance:_________________________________________________________

Parent’s or Guardian’s Name:_________________________________________________________

Father’s Employer:___________________________________ Phone#:_______________________

Mother’s Employer:___________________________________ Phone#:_______________________

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CHILD’S PLAY TELL US ABOUT YOUR CHILD

______________________________________

CHILD’S NAME

Confidential: Note that this information is for the CONFIDENTIAL USE of the teachers who will be working with your

child. The more completely you answer the questions, the better they will be able to understand him/her.

CHILD’S NAME:________________________________ NAME CALLED:_____________________

HOME ADDRESS:______________________________ CITY:_____________ZIP:______________

SUBDIVISION:____________________________________________________________________

DATE OF BIRTH:____________________ SEX:___________ RIGHT/LEFT HANDED___________

MOM’S NAME: ____________________________

MOM’S HOME PHONE:______________________ MOM’S CELL PHONE:____________________

MOM’S EMPLOYER:________________________ EMPLOYER ADDRESS:___________________

DAD’S NAME:_____________________________ ___________________

DAD’S HOME PHONE:______________________ DAD’S CELL PHONE:_____________________

DAD’S EMPLOYER:________________________ EMPLOYER ADDRESS:___________________

HOME AND PLAY EXPERIENCES

___________________

HOW MANY OTHER CHILDREN IN THE FAMILY?:_______________________________________

BOYS:____________ NAMES AND AGES:_____________________________________________

GIRLS:____________ NAMES AND AGES:____________________________________________

ADULTS LIVING IN THE HOME:______________________________________________________

PRIMARY CAREGIVER DURING THE DAY:_____________________________________________

PETS:____________________NAMES:________________________________________________

DOES ANYONE VISIT THE HOME FREQUENTLY?:______________________________________

WHEN PARENTS ARE AWAY WHO CARES FOR THE CHILD?_____________________________

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DOES HE/SHE HAVE A GOOD RELATIONSHIP WITH NEIGHBORS?________________________

DOES HE/SHE ENJOY PLAYING ALONE?______________________________________________

FAVORITE PLAY THINGS:___________________________________________________________

SPECIAL ATTACHMENTS:__________________________________________________________

SPECIAL SKILLS/FAVORITE PASTIME:________________________________________________

ATTENTION SPAN FOR STORIES:____________________________________________________

TYPE OF BOOKS HE/SHE ENJOYS:__________________________________________________

FAMILY MUSIC EXPERIENCES (PIANO, CDS, ETC.):____________________________________

HAS HE/SHE ATTENDED THIS OR ANY OTHER SCHOOL?_______________________________

SCHOOL NAME:_________________TYPE OF EXPERIENCE:_____________________________

DOES HE/SHE GO TO CHURCH SCHOOL?_________WHAT CHURCH?_____________________

IS HE/SHE INVOLVED IN FAMILY WORSHIP?___________________________________________

ACTIVITIES OUTSIDE THE HOME:____________________________________________________

FAMILY EXPERIENCES WHICH HAVE INFLUENCED HIM/HER SUCH AS TRIPS, ILLNESSES,

MOVES, FAMILY ADDITIONS, ETC.:___________________________________________________

________________________________________________________________________________

________________________________________________________________________________

BEHAVIOR

(Answers beyond “yes” or ”no” will be very helpful)

DOES YOUR CHILD FOLLOW A REGULAR DAILY ROUTINE?_____________________________

________________________________________________________________________________

HOW DOES HE/SHE REACT TO CHANGE OF ROUTINE?_________________________________

________________________________________________________________________________

WHAT IS HE/SHE LIKE AT MEALTIME?________________________________________________

________________________________________________________________________________

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DOES HE/SHE TAKE A NAP/REST TIME?:_____________________________________________

WHAT HAPPENS AT BEDTIME/NAPTIME:_____________________________________________

________________________________________________________________________________

TOILETING NAMES:________________________________________________________________

LIKES:___________________________________________________________________________

DISLIKES:________________________________________________________________________

PARTICULAR FEARS:______________________________________________________________

HOW IS CHILD’S ANGER EXPRESSED?_______________________________________________

HOW DO YOU DISCIPLINE YOUR CHILD?_____________________________________________

________________________________________________________________________________

HAS YOUR CHILD EVER BEEN HOSPITALIZED?_______________________________________

REASON:________________________________________________________________________

MEDICAL PROBLEMS:____________________________________________________________

MEDICATIONS;___________________________________________________________________

REASON TAKING MEDICATION:_____________________________________________________

ALLERGIES (ESPECIALLY FOOD, INSECT, MEDICATIONS):______________________________

________________________________________________________________________________

RECEIVING SPECIAL SERVICES OUTSIDE HOME? (EXAMPLE, SPEECH, PHYSICAL

THERAPY)_______________________________________________________________________

________________________________________________________________________________

CHILD’S STRENGTHS, IN YOUR OPINION:_____________________________________________

________________________________________________________________________________

________________________________________________________________________________

LANGUAGE SPOKEN IN HOME:______________________________________________________

PRIMARY LANGUAGE:_____________________________________________________________

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SECOND LANGUAGE______________________________________________________________

HAVE YOU DETECTED OR SUSPECTED DIFFICULTIES IN:

HEARING:___________ SIGHT:___________ SPEECH:___________ ATTENTION:_____________

OTHER;__________________________________________________________________________

IF SO, PLEASE STATE THE DIFFICULTIES AND THE TREATMENTS, IF ANY:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

NOW TAKE IT FROM HERE AND TELL US ABOUT HIM/HER

For example, is he/she imaginative, jealous, independent, talkative, easily angered, happy, active?

Also, state anything else which your child’s teachers might need to be aware of. For example,

adoption, job loss, divorce, separation, illness, etc.