The Magic DragonENROLLMENT
Early Childhood Enrichment ProgramGETTING ACQUAINTED QUESTIONNAIRE
The information you provide below will help our staff better understand your child and aid in his or her adjustment to our program. The contents of this questionnaire are strictly confidential.
FAMILY INFORMATION
Child’ s Name______
Nickname______Date of Birth_____/_____/_____
Mother’s Name (or Guardian)______Father’s Name (or Guardian)______
Mother is Asian? _____Yes _____ No Father is Asian? _____Yes _____No
Marital Status of parents (circle) Married Separated (how long______) Divorced (how long_____)
Is the child adopted? Yes No Does the child know he or she is adopted? Yes No
Custody/Living Arrangements______
SIBLINGS
Name______DOB__/__/__Grade____ Name______DOB__/__/__ Grade______
Name______DOB__/__/__Grade____ Name______DOB__/__/__ Grade______
Other Members of the Household (include Relationship and Age)
______
Do you consider yourself a part of Austin’s Asian Community? YES NO
PHYSICAL/HEALTH HISTORY:
Does your child have frequent colds? YES NO Specify:______
What medication does your child regularly take?______
Describe side effects, if any______
Has he/she had any serious injury, serious illness or convulsions?______
Specify______
Does he/she have a preferred hand? YES NO Which one?______
Describe any significant physical characteristics or limitations
______
Does he/she speak so that others understand? YES NO If not please illustrate______
______
Has your child undergone any tests such as sight, hearing or psychological? YES NO
If yes, please specify and attach results to this form______
What is your child’s primary language?
______(Speak) ______(Understand)
What other language(s) does your child:
______(Speak) ______(Understand)
SLEEPING HABITS:
Does your child nap during the day? YES NO When and how long?______
At what time does he/she go to bed at night?______What time does he/she awake?______
Describe any sleeping difficulties______
Is he/she dry all night? YES NO
(Continue on back)
The Magic DragonENROLLMENT
Early Childhood Enrichment ProgramGETTING ACQUAINTED QUESTIONNAIRE
(Cont’d)
TOILETING
Is your child toilet trained? YES NO At what age?______
For bowel movements? ______
What assistance does he/she needs for toileting?______
______
PLAY
With what does your child like to play?______
______
With what does he/she occupy him/herself when alone?______
With others?______
Has he/she had previous group experience? YES NO Describe______
______
What is his/her attitude toward that experience?______
______
Will he/she be starting any other group activity at this time?______
______
RELATIONSHIPS
How does your child react when you leave him/her?______
How do you prepare your child for leaving?______
Has he/she has to face any recent difficult situations ( hospitalization, emergency room treatment, death)?_
______How was your child helped to cope, before and after?______
Does your child have any specific fears?______
Describe his/her relationship to siblings______
HABITS
Does your child have any other comfort habits? YES NO Describe______
Does your child suck his/her thumb or fingers? YES NO ______
How does your child usual display anger?______
GUIDANCE
What method of behavior is used at home?______
What is the child’s reaction?______
What concerns do you have about your child’s behavior?______
______
______
In what ways would you like to see your child grow in the coming year?______
______
Is there anything else you would like us to know about your child?______
______
______
______
______
______
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