Application for a Preschool Child Name First Last Date MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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:Clay Yes No Scissors Yes No Painting Yes No Painting Yes No Blocks Yes No Water Play Yes No Story Hour Yes No Coloring Yes No Bathroom SkillsIs your child toilet trained? Yes No If trained, does he/she have accidents? Yes No Does your child wear diapers or pull ups at nap time or at night? Yes No Child is completely independent? Yes No Child needs reminding when involved? Yes No Child needs assistance with clothes? Yes No What words are used for urination and bowel movements?Nap TimeDaily Nap? Yes No Sometimes What 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? Yes No
