INFANT

REGISTRATION PACKET

Form J-800-2935 Revised June 2017

Page 1 of 6

ADMISSION INFORMATION

GENERAL INFORMATION

Operation’s Name: Director's Name:

Child’s Full Name: Child’s Date of Birth: Child Lives With: Mom Both parents

Dad Guardian Child’s Home Address:

Date of Admission: Date of Withdrawal: Name of Parent or Guardian Completing Form: Address of Parent or Guardian (if different from the child's):

List telephone numbers below where parents/guardian may be reached while child is in care.

Parent 1 Telephone No. Parent 2 Telephone No. Guardian's Telephone No. Custody Documents on File: Yes No

Give the name, address, and phone number of the responsible individual to call in case of an emergency if parents/guardian cannot be reached:

Relationship:

I authorize the child care operation to release my child to leave the child care operation ONLY with the following persons. Please list name and telephone number for each. Children will only be released to a parent or guardian or to a person designated by the parent/guardian after verification of ID. Name and Phone Number: Name and Phone Number: Name and Phone Number:

CONSENT INFORMATION

CHECK ALL THAT APPLY: 1.TRANSPORTATIONI give consent for my child to be transported and supervised by the operation's employees:

for emergency care on field trips to and from home to and from school

2.FIELD TRIPSI give consent for my child to participate in field trips.

I do not give consent for my child to participate in field trips. Comments:

3.WATER ACTIVITIESI give consent for my child to participate in the following water activities:

water table play sprinkler play splashing/wading pools swimming pools aquatic playgrounds

The I School Dana Capers

Form J-800-2935 Revised June 2017

Page 2 of 6

CONSENT INFORMATION

CHECK ALL THAT APPLY: 4.RECEIPT OF WRITTEN OPERATIONAL POLICIESI acknowledge receipt of the facility's operational policies, including those for:

Discipline and guidance Procedures for release of children

Suspension and expulsion Illness and exclusion criteria

Emergency plans Procedures for dispensing medications

Procedures for conducting health checks Immunization requirements for children

Safe sleep Meals and food service practices

Procedures for parents to discuss concerns with the director

Procedures to visit the center without securing prior approval

Procedures for parents to participate in operation activities

Procedures for parents to contact Child Care Licensing, DFPS, Child Abuse Hotline, and DFPS website

5. MEALSI understand that the following meals will be served to my child while in care:

None Breakfast Morning snack Lunch Afternoon snack Supper Evening snack

6. DAYS AND TIMES IN CAREMy child is normally in care on the following days and times:

Day of the Week AM PM

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION

In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to: Name of Physician: Address: Phone Number:

Name of Emergency Care Facility: Address: Phone Number:

I give consent for the facility to secure any and all necessary emergency medical care for my child.

Signature - Parent or Legal Guardian

Form J-800-2935 Revised June 2017

Page 3 of 6

CHILD'S ADDITIONAL INFORMATION SECTION

List any special needs that your child may have, such as environmental allergies, food intolerances, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregivers should be aware of:

Does your child have diagnosed food allergies? Yes No Plan submitted on:

Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY).

Signature - Parent or Legal Guardian: Date Signed:

SCHOOL AGE CHILDREN

My child attends the following school:

Name of School: School Phone Number:

My child has permission to (check all that apply):

walk to or from school or home ride a bus be released to the care of his/her sibling under 18 years old

Authorized pick up/drop off locations other than the child’s address:

ADMISSION REQUIREMENT

If your child does not attend pre-kindergarten or school away from the child care operation, one of the following must be presented when your child is admitted to the child care operation or within one week of admission.

Please check only one option:

1. HEALTH CARE PROFESSIONAL'S STATEMENT: I have examined the above named child within the past year and find that he or she is able to take part in the day care program.

Health Care Professional's Signature: Date Signed:

2. A signed and dated copy of a health care professional's statement is attached.

3. Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of. I have attached a signed and dated affidavit stating this.

4. My child has been examined within the past year by a health care professional and is able to participate in the day care program. Within 12 months of admission, I will obtain a health care professional's signed statement and submit it to the child care operation.

Name and Address of Health Care Professional:

Signature - Parent or Legal Guardian: Date Signed:

Form J-800-2935 Revised June 2017

Page 4 of 6

REQUIREMENTS FOR EXCLUSION

I have attached a signed and dated affidavit stating that I decline immunizations for reason of conscience, including religious belief, on the form described by Section 161.0041 Health and Safety Code submitted no later than the 90th day after the affidavit is notarized.

I have attached a signed and dated affidavit stating that the vision or hearing screening conflicts with the tenets or practices of a church or religious denomination that I am an adherent or member of.

VISION EXAM RESULTS

R 20/ L 20/ Pass Fail

Signature: Date Signed:

HEARING EXAM RESULTS

Ear 1000 Hz 2000 Hz 4000 Hz Pass or Fail

Right Pass Fail

Left Pass Fail

Signature: Date Signed:

VACCINE INFORMATION

The following vaccines require multiple doses over time. Please provide the date your child received each dose.

Vaccine Vaccine Schedule Dates Child Received Vaccine

Hepatitis B Birth (first dose)

1–2 months (second dose)

6–18 months (third dose)

Rotavirus 2 months (first dose)

4 months (second dose)

6 months (third dose)

Diphtheria, Tetanus, Pertussis 2 months (first dose)

4 months (second dose)

6 months (third dose)

15–18 months (fourth dose)

4–6 years (fifth dose)

Haemophilus Influenza Type B 2 months (first dose)

4 months (second dose)

6 months (third dose)

12–15 months (fourth dose)

Form J-800-2935 Revised June 2017

Page 5 of 6

VACCINE INFORMATION

The following vaccines require multiple doses over time. Please provide the date your child received each dose.

Vaccine Vaccine Schedule Dates Child Received Vaccine

Pneumococcal 2 months (first dose)

4 months (second dose)

6 months (third dose)

12–15 months (fourth dose)

Inactivated Poliovirus 2 months (first dose)

4 months (second dose)

6–18 months (third dose)

4–6 years (fourth dose)

Influenza Yearly, starting at 6 months. Two doses given at least four weeks apart are recommended for children who are getting the vaccine for the first time and for some other children in this age group.

Measles, Mumps, Rubella 12–15 months (first dose)

4–6 years (second dose)

Varicella 12–15 months (first dose)

4–6 years (second dose)

Hepatitis A 12–23 months (first dose)

The second dose should be given 6 to 18 months after the first dose.

PHYSICIAN OR PUBLIC HEALTH PERSONNEL VERIFICATION

Signature or stamp of a physician or public health personnel verifying immunization information above:

Signature : Date Signed:

VARICELLA (CHICKENPOX)

Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement: My child had varicella disease (chickenpox) on or about (date) and does not need varicella vaccine.

Parent's Signature: Date Signed:

ADDITIONAL INFORMATION REGARDING IMMUNIZATIONS

For additional information regarding immunizations, visit the Texas Department of State Health Services’ website at www.dshs.state.tx.us/immunize/public.shtm.

Form J-800-2935 Revised June 2017

Page 6 of 6

TB TEST (IF REQUIRED)

Positive Negative Date:

GANG FREE ZONE

Under the Texas Penal Code, any area within 1,000 feet of a child care center is a gang-free zone, where criminal offenses related to organized criminal activity are subject to harsher penalties.

PRIVACY STATEMENT

DFPS values your privacy. For more information, read our Privacy and Security Policy online at http://www.dfps.state.tx.us/policies/privacy.asp.

SIGNATURES

Child's Parent or Legal Guardian:

XDate Signed:

Center Designee:

XDate Signed:

Form J-800-2550 New January 2017

Page 1 of 2

OPERATIONAL POLICY ON INFANT SAFE SLEEP

SAFE SLEEP POLICY

All staff, substitute staff, and volunteers at

will follow these safe sleep recommendations of the American Academy of Pediatrics (AAP) and the Consumer Product

Safety Commission (CPSC) for infants to reduce the risk of Sudden Infant Death Syndrome/Sudden Unexpected Infant

Death Syndrome (SIDS/SUIDS):

Always put infants to sleep on their backs unless you provide an Infant Sleep Exception form 2710 signed by

the infant's health care professional [§746.2427 and §747.2327].

Place infants on a firm mattress, with a tight fitting sheet, in a crib that meets the CPSC federal requirements

for full size cribs and for non-full size cribs [§746.2409 and §747.2309].

For infants who are younger than 12 months of age, cribs should be bare except for a tight fitting sheet and a

mattress cover or protector. Items that should not be placed in a crib include: soft or loose bedding, such as

blankets, quilts, or comforters; pillows; stuffed toys/animals; soft objects; bumper pads; liners; or sleep

positioning devices [§746.2415 and §747.2315]. Also, infants must not have their heads, faces, or cribs

covered at any time by items such as blankets, linens, or clothing [§746.2429 and §747.2329].

Do not use sleep positioning devices, such as wedges or infant positioners. The AAP has found no evidence

that these devices are safe. Their use may increase the risk of suffocation [§746.2415 and §747.2315].

Ensure that sleeping areas are ventilated and at a temperature that is comfortable for a lightly clothed adult

[§746.3407(10) and §747.3203(10)].

If an infant needs extra warmth, use sleep clothing

(insert type of sleep clothing that will be used, such as sleepers or footed pajamas) as an alternative to

blankets [§746.2415 and §747.2315].

Place only one infant in a crib to sleep [§746.2405 and §747.2305].

Infants may use a pacifier during sleep. But the pacifier must not be attached to a stuffed animal or the

infant’s clothing by a string, cord, or other attaching mechanism that might be a suffocation or strangulation

risk [§746.2415 and §747.2315].

If the infant falls asleep in a restrictive device other than a crib (such as a bouncy chair or swing, or arrives to

care asleep in a car seat), move the infant to a crib immediately, unless you provide an Infant Sleep Exception

form 2710 signed by the infant's health care professional [§746.2426 and §747.2326].

Our child care program is smoke-free. Smoking is not allowed in Texas child care operations (this includes e-

cigarettes and any type of vaporizers) [§746.3703(d) and §747.3503(d)].

Actively observe sleeping infants by sight and sound [§746.2403 and §747.2303].

If an infant is able to roll back and forth from front to back, place the infant on the infant's back for sleep and

allow the infant to assume a preferred sleep position [§746.2427 and §747.2327].

Awake infants will have supervised “tummy time” several times daily. This will help them strengthen their

muscles and develop normally [§746.2427 and §747.2327].

Do not swaddle an infant for sleep or rest unless you provide an Infant Sleep Exception form 2710 signed by

the infant’s health care professional [§746.2428 and §747.2328].

Form J-800-2550 New January 2017

Page 2 of 2

PRIVACY STATEMENT

DFPS values your privacy. For more information, read our privacy policy at: http://www.dfps.state.tx.us/policies/privacy.asp.

SIGNATURES

This policy is effective on: (date)

Child's name:

Signed by:

X

Director/Owner

Date signed:

Signed by:

X

Staff member

Date signed:

Signed by:

X

Parent

Date signed:

Form J-800-2710 New February 2017

Page 1 of 2

INFANT-SLEEP EXCEPTION HEALTH-CARE PROFESSIONAL RECOMMENDATION

Purpose: When a health-care professional determines that it is medically necessary for an infant to sleep in an alternative position (other than sleeping on the infant's back), sleep in a restrictive device (such as a bouncer seat or swing), or needs to be swaddled to sleep, use this form to ensure that a licensed child-care center, licensed child-care

home, or registered child-care home that cares for the infant meets the minimum standards required by Texas Human Resources Code §42.042(e)(8). The standards for these operations require the operation to:

follow the directions of an infant's health-care professional to provide specialized medical assistance to theinfant; and

maintain, while active, this form and any other directions from the health-care professional that theparent provides to the operation [See §746.603(a)(10) or §747.603(a)(9)]. Keep the exception form in

the infant's classroom, so that a caregiver may refer to the health-care professional's instructions.

Directions: This exception will not be effective until all sections and signatures are complete. Once completed the exception is acceptable for use by the child-care operation.

INFANT'S INFORMATION

Infant’s Name: Infant’s Date of Birth: Infant’s Age:

Parent/Guardian's Name:

Address:

Home Phone: Work Phone:

Fax: Email:

The infant's health-care professional must complete the following section.

HEALTH-CARE PROFESSIONAL INFORMATION

Name of Infant's Health-Care Professional:

Name of Practice:

Address:

Phone: Fax:

Email:

The Texas child care minimum standards (§§746.2426, 746.2427 and 746.2428 for child-care centers or §§747.2326,

747.2327 and 747.2328 for licensed or registered child-care homes) require child-care operations to place all infants on their backs to sleep in a crib and to ensure that infants do not sleep in restrictive devices and are not laid down to sleep swaddled. But based on the advice of the infant's health-care professional, when medically necessary the center

may be authorized to use an alternative-sleep position, restrictive device, or swaddle for the infant due to medical reasons.

The above-named infant has the following medical condition that necessitates an alternative-sleep position, allow for sleep in a restrictive device, or requires swaddling for sleeping:

Form J-800-2710 New February 2017

HEALTH-CARE PROFESSIONAL INFORMATION

Please describe the appropriate sleep position/restrictive device/ swaddling technique to be used for the above-

named infant and include the effective dates for the exception:

Effective Dates of Exception: from to

Health-Care Professional's Signature: Date Signed:

WAIVER OF LIABILITY

Page 2 of 2

I affirm and acknowledge that the below-named child-care operation has provided me with the operation's safesleep policy.

I further authorize the child-care operation and its caregivers to place my infant in an alternative-sleep position,restrictive device, or swaddling at the recommendation of my infant's health-care professional, as describedabove.

I, as the parent or guardian of the above mentioned infant, release and hold harmless the below-named child-care operation, its officers, directors, caregivers, and employees from any and all liability whatsoever associated

with harm to my infant due to Sudden Infant Death Syndrome (SIDS).

Parent or Guardian’s Signature: Date Signed:

An authorized official with the child-care operation must complete the following section.

CHILD-CARE OPERATION INFORMATION AND SIGNATURE

Name of Child-Care Operation: Operation Number:

Operation Representative's Signature: Date Signed:

PRIVACY STATEMENT

DFPS values your privacy. For more information, read our privacy policy at: http://www.dfps.state.tx.us/policies/privacy.asp.

1

Attention Parents: Per the Texas Department of Family and Protective Services, Childcare Licensing Department: if your child requires specialized medical assistance, you must fill out the this form.

If your child has a food allergy; the Texas childcare Licensing Department requires us to have you fill out the form below and attach a signed/ dated copy of your child’s Emergency Care Plan from your child's physician. We must have a food allergy emergency plan for each child with a known food allergy that has been diagnosed by a health-care professional. The child’s heath care professional and parent must sign and date the plan. You must keep a copy of the plan in the child’s file. The Emergency Care Plan for food allergies MUST have the following information per Texas Childcare Licensing Department. *A food allergy emergency plan is an individualized plan prepared by the child’s health care professional that includes:(1) a list of each food the child is allergic to; (2) possible symptoms if exposed to a food on the list; and (3) the steps totake if the child has an allergic reaction.

1. Check any special medical condition that your child may have:

No specific medical condition (please skip to next page to sign and date) Asthma Diabetes Gastrointestinal or feeding concerns including special diet and supplements Cerebral palsy / motor disorder Epilepsy / seizure disorder Any disorder including Cognitively Disabled, LD, ADD, ADHD, or Autism Milk allergy. If a child is allergic to milk, attach a statement from the medical professional

indicating the acceptable alternative. Food allergies (Emergency Care Plan REQUIRED)– Specify food(s): ___________________

________________________________________________ Non-food allergies – Specify: ___________________________ _____________ Other condition(s) requiring special care – Specify:

______________________________________________ ______________ ____ ___________________________________________________________________________________________________________________________

2.Triggers that may cause problems - Specify: _________________________________________

3. Signs or symptoms to watch for – Specify: ________________________________________________________________________________________________________

4. Does this condition require medical assistance (any assistance other than medication that a childneeds (examples: apnea monitor, protective helmet, leg brace, etc)?

No (skip to sign and date) Yes (see below and continue with form)

Health History & Emergency Care Plan

2

Teaching Staff:

6. When to call parents regarding symptoms or failure to respond to treatment: _________________________________________________________________________________________________

7. When to consider that the condition requires emergency medical care or reassessment:________________________________________________________________________________________________________________________________________________________________

8. Additional information that may be helpful to the child care provider: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

My signature below is indication that I understand the medical conditions and guidelines for treating such condition(s) that are outlined above.

______________________________ __________________________ Parent or Guardian's Signature Date Signed

______________________________ __________________________ Administrative Signature Date Signed

5. Identify any child care staff to whom you have given specialized training / instructions to help treatsymptoms:

Administrative Personnel:

3

In a parent-participation preschool, many photos and videos are taken of the children singly and in groups by The I-School staff and parents. These photos/videos are often posted at school; used in projects; and shared amongst families in the program via emails and postings to our Facebook page. They may also be used for marketing purposes such as on a brochure or newspaper publication; on public pages such as our Facebook page, YouTube Channel, and other social media outlets associated with our program. Names will never be used on public pages.

Please note that the usage of such photos and videos will be at the discretion of the I-School Director and/or staff and permission will not be sought for specific publication purposes.

Please sign below to indicate that you have reviewed and agree to the Photograph & Videotape Policy at The I School:

Child’s name (print): _____________________________________________________

Parent’s name(s) (print): __________________________________________________

Parent’s signature(s): ____________________________________________________

Date: __________________________________________________________________

Photograph & Videotape Acknowledgement

4

SCHOOL ACTIVITIES

I, ____________________, give my child premission, ______________,

o participate in all on-site school-wide activities at The “I” School.

Parent/Guardian Signature Date

PERMISSION FORAPPLICATION OF INSECT REPELLENT

I ________________________ give permission for The I School to apply mosquito repellent to my child _____________________ before going outside to the playground. This mosquito repellent will be supplied by The I School and will be applied as per label directions.

___________________________ ____________________ Parent/Guardian Signature Date

PERMISSION FOR

5

• Discipline must be:

1. Individualized and consistent for each child;2. Appropriate to the child's level of understanding;3. Directed toward teaching the child acceptable behavior and self-control

• A caregiver may only use positive methods of discipline and guidance that encourage self-esteem,self-control, and self-direction, which include at least the following:

1. Using praise and encouragement of good behavior instead of focusing only upon unacceptablebehavior;2. Reminding a child of behavior expectations daily by using clear, positive statements;3. Redirecting behavior using positive statements; and4. Using brief supervised separation or time out from the group, when appropriate for the child's ageand development, which is limited to no more than one minute per year of the child's age.

• There must be no harsh, cruel, or unusual treatment of any child. The following types of disciplineand guidance are prohibited:

1. Corporal Punishment or threats of corporal punishment;2. Punishment associated with food, naps or toilet training;3. Pinching, shaking or biting a child;4. Hitting a child with a hand or instrument;5. Putting anything in or on a child's mouth;6. Humiliating, ridiculing, rejecting or yelling at a child;7. Subjecting a child to harsh, abusive or profane language8. Placing a child in a locked or dark room, bathroom or closet with the door closed; and/or9. Requiring a child to remain silent or inactive for inappropriately long periods of time for the child'sage.

Texas Administrative Code, Title 40, Chapters 746 and 747, Subchapters L, Discipline and Guidance; TDPRS-CCL

My signature below verifies that I have read and received a copy of this discipline and guidance

policy.

Child’s Name

Parent/Guardian Signature Date

Check one please: Parent Employee/Caregiver

Discipline and Guidance Policy for The “I” School:

6

Student Information Consent & Waiver

The purpose of this form is to give The I School Administration permission to give other parents/legal guardians, etc. contact information (ie. shared with the PAC in order to communicate about happenings, events, etc. and also with other parents in the event of birthday parties, etc.

Child’s Name: Date of Birth:

I am the parent/legal guardian of the child named above, and I agree to the following information being made available to other individuals affiliated with The I School.

Home Telephone Number(s): Work Telephone Number(s): Home Address: E-Mail Address(es):

Name of Parent/Guardian:

Signature: Date:

7

Parent Handbook Acknowledgement

I (We) have read and agree to The I School's policies and procedures as described in the Parent Handbook.

I understand that these guidelines may change periodically.

Child's Name (Please Print) ____________________________________________________

Parent or Legal Guardian Signature_______________________________________________

Date_________________________

Parent or Legal Guardian Signature_______________________________________________

Date_________________________

Administrative Signature________________________________

Date____________________

After signing this acknowledgement, please either:

• Remove this page from your Parent Handbook and return it with your enrollment packet;

OR

• Sign the copy of the Acknowledgement that is located in the enrollment packet;

OR

• You may e-mail the director with the following statement, “I have received the I School’s policies andprocedures as described in the Parent Handbook. I understand that these guidelines may changeperiodically”.

8

Child’s Name:

Classroom: Days per Week:

I/We agree to pay $_____ _______ monthly starting on ________________

I will pay this amount via:

______On-line Quickbooks _______ Check

All parents requesting to withdraw their child will be required to submit a written 30 day notice.

• A 2.5% site fee per transaction will be accessed if paying by credit card.

• We accept payments by check. There is a locked drop-box located on the side of the front desk tosubmit these payments.

• A late charge of $25.00 will be applied to your account for any payments made after the 5th of themonth.

• An additional fee of $75.00 will be applied to your account for any payments made after the 15th ofeach month. After the 15th of the month, $10.00 a day will be applied to your account.

• If you have made special arrangements to pay your tuition weekly, your payment will be due on theFriday before the week. A late fee of $25.00 will be applied to your account if payment is not receivedby Monday morning.

________(initial) I/We understand that all outstanding financial obligations and commitments must be cleared up by the end of the current school year in order to secure a spot for next year.

Parent/Guardian Signature:________________________________ Date: ____________________

Parent/Guardian Name (print): _______________________________ Date: ____________________

Tuition Agreement

9

PLEASE KEEP THIS PAGE

Immunization Records Please bring in your child’s shot records upon enrollment or have your child’s physician fax us your child’s shot records. Any time your child gets updated shots please be sure to bring us a copy or have your child’s physician fax over a copy. Our fax number is 832-222-9226.

Well Health Statement from Doctor Please have your child’s physician sign the Well Health Statement on pg. 2 of Admission Information. Your child’s physician can either sign and date pg. 2 of Admission Information or your child’s physician can write a Well Health letter, sign, and date it and then fax it to us. Our fax number is 832-222-9226.

Watch Me Grow - Camera Log-in All of the classrooms and the playground have a camera which can be viewed externally by parents.

To View: Please visit – watchmegrow.com/signup Click - “I am a Parent or Guardian” Under Select Your Center put in The I School’s telephone number; 832-222-9220. Then, follow the steps to complete your account.

The cameras may from time to time be unavailable for maintenance or other reasons. If you feel like there may be an issue, or if you have trouble accessing the site please contact us via email, theischooloffice@gmail.com.

FACEBOOK Go check us out and be sure to like us on Facebook! https://www.facebook.com/theischoolkaty.

GETTING ACQUAINTED... Date:___ ______

This information is confidential and is intended for your child's teacher to understand your child better. The more complex your answers are, the better the teacher can help your child.

Date of Birth: Child's Name: Name Called:

PARENT INFORMATION:

Dad's Name: Daytime contact phone number: E-Mail address:

Mom's Name: Daytime contact phone number: E-Mail address:

Who may we thank for your referral to The “I” School?

DAILY LIVING:

Child's Ethnic Background/Heritage: Language(s) Spoken: Siblings:

Name: Age: Name: Age: Name: Age:

With which adults does your child have frequent contact:

No ___ Has your child previously attended an early childhood program? Yes Which one?

How long have you lived in this area? Other countries in which you have resided (include length of time):

Have there been any family experiences that might have influenced your child (ie. moves, deaths, births, divorce, etc.)? Please explain:

What adults live at home with your child? What pets live at home with your child?

10

Do you follow a regular routine? Please describe:

How does your child react to a change in the routine?

Are there any group activities done outside of the home (Please list):

When? How long per day? Does your child watch TV?

How does your child eat? Slowly, Quickly, Feeds himself/herself Some, Little,

What is your child's typical eating pattern?

What does your child like to eat? What does your child NOT like to eat? Are there any restrictions (please describe)? How well does your child use table utensils (cup, fork, spoon)?

Does your child indicate bathroom needs (explain)? What are your child's regular bladder and bowel patterns?

Words for bowel movements? Word(s) for urination? Special words for body parts?

What are your child's sleeping patterns? Awakes at in the morning, naps for hours at in the afternoon, Goes to bed at at night.

How many hours? Does your child sleep through the night?

SOCIAL RELATIONSHIPS and PLAY:

When? How Long? Do you play with your child at home? Does your child prefer to play indoors/outdoors?

Does your child play well alone? What activities does he/she prefer to do while playing alone?

What is your child's favorite toy(s)?

What age(s) are your child's most frequent playmates?

Does your child need extra time/preparation to change from one activity to another?

animals, rough children, Is your child frightened by any of the following items: loud noises, new experiences, the dark, storms, or other(s) - please list:

11

What type of temperament does your child usually have: quiet, happy, teary, playful, aggressive, observant, bossy,

curious, shy, cautious, talkative,

friendly/outgoing.

Does your child have any problems with mood or behavior (please describe):

Who does most of the disciplining? What form of discipline do you use at home? How does your child react to discipline? What causes your child to show a temper? How do you respond?

How do you comfort your child? Does your child use special comforting items (such as a blanket, stuffed animal, doll, etc.)? If so, does this item have special name?

DEVELOPMENT:

_Language Development, )

Do you suspect any difficulties in the following areas: ___ Hearing, ___ ___Speech, ____ __Vision, _____ ______other (specify: If so, please describe:

Does your child show any problems with walking or moving? If so, please describe:

Does your child have any problems using his or her hands and grasping things using pincher control? If so, please describe:

What are the goals you have for your child this school year?

Parents, please use the space below to let us know the wonderful things about your child that they may be too shy to share. Any words of advice that will help us to know them better is encouraged (you can tattle on them too)! Thank you!

Comments:

12

13