Questionnaire 1 Your Child2 2nd Child3 Pickup People4 Grandparent Info Getting to Know Your Child1. Child's Name* First Last 2. What are your child's favorite activities?3. Does your child have a security item?pacifier, blanket, stuffed animal, etc.YesNoWhat is it? When does your child use it? What do you call it?4. Does your family have a pet? What is its name?5. What time does your child typically go to bed?6. Does your child nap?YesNo7. Do other people care for your child? How often?8. Does your child exhibit separation anxiety?9. Does your child have any fears?10. What behaviors are you finding challenging to deal with right now?11. Please describe your form of discipline at home.12. Do you have any concerns about your child? If yes, please explain.13. Does your child have any special dietary needs? If yes, what are they?14. As a parent, what are your expectations of your child’s growth and development while in our program?15. What goals would you like us to work toward together this year?16. Is there anything else you'd like us to know about your child?17. Are you interested in serving as a parent resource to our curriculum? Do you have special talents, skills, or cultural knowledge that you would like to share with our program? Second ChildDo you have a second child in school?YesNoShow 2nd child if answer is yes1. Child's Name* First Last 2. What are your child's favorite activities?3. Does your child have a security item - pacifier, blanket, stuffed animal, etc.?YesNoWhat is it? When does your child use it? What do you call it?4. What time does your child typically go to bed?5. Does your child nap?6. Does your child exhibit separation anxiety?7. Does your child have any fears?8. What behaviors are you finding challenging to deal with right now?9. Do you have any concerns about your child? If yes, please explain.10. Does your child have any special dietary needs? If yes, what are they?11. As a parent, what are your expectations of your child’s growth and development while in our program?12. What goals would you like us to work toward together this year?13. Is there anything else you'd like us to know about your child? Approved Pickup PeopleWill there be anyone else picking up your child from school?YesNoApproved Pickup Person 1 First Last Relationship to Child Approved Pickup Person 2 First Last Relationship to Child Approved Pickup Person 3 First Last Relationship to Child Approved Pickup Person 4 First Last Relationship to Child Grandparent InfoWant your parents to receive Rosh Hashana and Chanukah cards? Enter their info below! We may also reach out to them for Annual Fund.Grandparents (Set 1) First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Grandparents (Set 2) First Last Address 2 Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Grandparents (Set 3) First Last Address 2 Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
