Kindergarten Questionnaire
Help us get to know your child
This information will be used by your child's teacher, and school and board staff to better meet the needs of your child.
1. Date ______
2. Child's name ______
3. Date of birth (day) ______(month) ______(year) ______
4. Parents/guardians Home Phone Work Phone
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______
5. Brothers or sisters
Names Age School
______
______
______
6. Daytime caregiver Home Babysitter Daycare
Name ______Phone Number ______
7. The following individuals may pick my child up from school:
Name Relationship
______
______
______
______
______
8. Special medical information (allergies, asthma, hearing, medications)
______
______
______
9. Languages spoken at home with your child ______
10. Languages your child understands well ______
11. Languages your child speaks well ______
12. In your child's first language:
- At what age did your child begin to talk using single words (e.g. "no," "more")? ______
- At what age did your child use several words together (speak in short sentences)? ______
- Does your child now speak in complete sentences using proper grammar? Yes No If no, please explain ______
- Can your child tell a story in his or her first language to tell about a recent experience with enough details to make sense? Yes No If no, please explain ______
- Can your child carry out two or three simple directions given all at once (e.g. "Put your blocks away, turn off the TV and get your coat")? Yes No If no, please explain ______
13. Do people outside the family understand most of what your child says? Yes No If no, please explain ______
14. Does your child pronounce words clearly in his or her first language—the same way as other children the same age? Yes No If no, please explain ______
15. Does your child stutter, stammer or struggle to get words out when talking (frequently repeat words or sounds like "I-I-I-I")? Yes No If yes, please explain ______
16. Does your child have a hoarse voice? Yes No
17. Has your child's vision been tested? Yes No
Where ______When ______
Results ______
18. Has your child's hearing been tested? Yes No
Where ______When ______
Results ______
19. Has your child had an ear infection? Yes No
More than 5 _____ # of sets of tubes _____ Age(s) when tubes inserted ______
20. Does someone read out loud to your child? Yes No
How often? Daily Weekly Rarely Language used ______
21. Can your child rhyme (e.g. "Sandy—Dandy")? Yes No
22. Is your child interested in letters (e.g. singing the alphabet song, magnetic letters, reading signs)? Yes No
23. Has your child ever received speech/language therapy? Yes No
Where ______When ______
Is there a report you can share with the school? ______
24. Do you have any concerns about your child's speech and language or communication development? Yes No Please explain ______
25. Is there any history of speech/language or reading/writing problems in your family? Yes No Please explain ______
26. If your child is entering Year One Kindergarten (JK) and you would like to discuss any speech/language concerns with a Speech-Language Pathologist, please call Halton-Peel Preschool Speech and Language Services at 905-855-3557 and they will be happy to help you. Let your child's teacher know about your concerns.
27. If your child is entering Year Two Kindergarten (SK), would you like to discuss any speech or language concerns with a school Speech-Language Pathologist? Yes No
28. Pre-Kindergarten experience Yes No
Organization/Facility / Starting age / Length of participationDaycare
Nursery School
Peel Hub or Readiness Centre
Recreational experiences
Support service (e.g. occupational therapy, speech therapy)
Other
29. Please share any additional information that you believe would help us get to know your child.
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______
______
______
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______
OFFICE USE ONLY
Reviewed by School SLP ______Action Required ______
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