YPC/Children's House Parent Questionnaire

Child's First Name:*

Child's Middle Name: *

Child's Last Name*

Child's Nickname:

Child's Date of Birth:*

Child's Gender:*

Class Applying for:* Young People's Community Children's House

YPC = Young People's Community (15m-3yr) CH = Children's House (3yr-6yr)

Is there any present information concerning your child's pre-natal or birth experience that you would like to share?

Does your child have any suspected special needs?

Has your child been hospitalized? Duration? Reason?

Is your child on any routine medications? If yes, please state why:

Does your child have any Allergies / Medical Conditions?*

Name of Allergy and/or Medical Conditions:

Treatment of Allergies or Medical Condition:

Please share with us any medical history, or diagnostic evaluations (educational, physical or psychological) that pertain to your child:

At what age did your child roll over?

At what age did your child sit up?

At what age did your child crawl?

At what age did your child walk?

What time does your child get up in the morning?

What time does your child go to bed at night?

Does your child nap during the day?

When?

How long?

How do you see your child's social and emotional interactions?

Does your child relate to new people easily?

What activities do you enjoy with your child?

Does your child play well alone?

Does your child play well with children his/her own age?

Does your child play well with older children?

Does your child play well with his/her siblings?

Does your child have any hobbies, sports, special interests, unique capabilities, or talents?

Name recent programs that your child has been in (school, camp, church programs).

What responsibilities, if any, does your child have at home?

Contact Person Name:*

Phone Number*

Additional comments or observations you feel we should know to help us understand your child better: