Child's Name: *
Child's Date of Birth: *
Date Format: MM slash DD slash YYYY
Please describe your child’s temperament as observed thus far. How would you describe their social and emotional development?
SCHOOL/CARE EXPERIENCE: *
What is your child’s current care situation? Has your child had experience in a group-care environment or situation? How does your child handle separation?
Does your child feed himself or herself? Do they currently use a pacifier? Please describe your child’s verbal skills.
GROSS MOTOR/FINE MOTOR: *
Does your child move independently? Are they crawling, climbing, standing, walking? Are they able to grasp small objects, like Cheerios?
SPECIAL CONSIDERATIONS: *
Are there any special considerations which you would like to share or additional information you feel would be important for us to know when considering your child’s classroom placement? Has your child been assessed, or recommended for assessment, for any reason, including, but not limited to speech or hearing, sensory integration, or behavioral challenges? If there are no special considerations, please write “none.”