Application for a Preschool Child Name First Last Date Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country With whom does the child reside?Name and ages of siblings or other children living in the home. Other pertinent information you would like to share. Does your child have any special concerns that would affect the school experience (allergies, asthma, etc.)?Background InformationHas your child attended any other day care or preschool? If yes, name of school:Does your child take any medication daily? If yes, please explain.Does your child have any food allergies?Does your child have any comforting needs, strong attachments?Types of home discipline most frequently used.Most young children are afraid of some things. Please list any fears. (Example: darkness, animals, sirens, being left alone, loud noises, crying, etc.)Your child’s favorite activities:Favorite recreational pastime.Does your child have any habits, needs, schedules, etc. that you feel we should know about in attempting to personalize our approach? If so, please describe.Child's Development HistoryDoes he/she have difficulty speaking?Does he/she use any special words to describe his/her needs?Do you feel your child will adjust easily to the Center?How well does he/she get along with other children?Does your child have any needs requiring special attention?Do you have any special request?We encourage parent participation. If you have any skills or hobbies you would like to share with the children or staff, please let us know.Is your child left-handed or right-handed?Has your child had experience with the following:ClayYesNoScissorsYesNoPaintingYesNoPaintingYesNoBlocksYesNoWater PlayYesNoStory HourYesNoColoringYesNoBathroom SkillsIs your child toilet trained?YesNoIf trained, does he/she have accidents?YesNoDoes your child wear diapers or pull ups at nap time or at night?YesNoChild is completely independent?YesNoChild needs reminding when involved?YesNoChild needs assistance with clothes?YesNoWhat words are used for urination and bowel movements?Nap TimeDaily Nap?YesNoSometimesWhat time does your child go to bed at night?Does your child have any special habits at bed time or nap time? (sleeping with a special blanket, stuffed animal, etc.) EatingWhat is your child’s general attitude toward eating?Favorite foods.Least favorite foods.Is your child typically hungry at mealtime?YesNo
