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Getting to Know You Questionnaire

Please complete the questionnnaire about your child (for preschool families only):

Child's Name:*

Answer Required

Name child prefers to be called:

Answer Required

Date of birth:*

Answer Required

Parent/Guardian #1 Name:*

Answer Required

Parent/Guardian #1 Occupation:

Answer Required

Parent/Guardian #2 Name:

Answer Required

Parent/Guardian #2 Occupation:

Answer Required

Are there any other parents/guardians/relatives living in the household with your child?

Answer Required

Is English your child's first language?*

Answer Required

Yes

No

What is your child's secondary language?

Answer Required

Is there any information about your family that you believe would be useful in caring for your child (i.e. separated parents, cultural traditions, family situations, etc...)?

Answer Required

Does your child have any medical conditions that we should know about (i.e. asthma, seizures, etc...)?

Answer Required

Is your child required to take medication for these things? If so, please explain:

Answer Required

Does your child get frequent colds, earaches, fevers, sore throats, stomach aches, vision problems, or skin rashes?

Answer Required

Is your child potty trained?*

Answer Required

Yes

No

What age did they start?

Answer Required

Please describe any assistance they may need:

Answer Required

Does your child take regular naps at home?*

Answer Required

Yes

No

What time do they go to bed at night?*

Answer Required

Has your child had group play experiences?*

Answer Required

Yes

No

Does your child like to play alone, with adults, or with other children?*

Answer Required

How does your child relate to adults?*

Answer Required

Which activities has your child experienced? (check all that apply)*

Answer Required

Playdough

Glue

Scissors

Blocks

Painting

Puzzles

Other:

What’s your child’s favorite activity at home? *

Answer Required

When and how does your child express frustration?*

Answer Required

When and how does your child express anger? *

Answer Required

When and how does your child express fear? *

Answer Required

Does your child have any special fears? (dogs, loud noises, etc…) *

Answer Required

Does your child use electronics at home? (cell phones, tablets, video games, television, etc...)*

Answer Required

Does your child accept direction easily? *

Answer Required

Describe your child’s attention span: *

Answer Required

Describe your child’s personality and behavior: *

Answer Required

What kind of discipline do you find most effective at home? *

Answer Required

Do you have any concerns about your child’s development or behavior? *

Answer Required

Thank you for completing this questionnaire!

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Northern Light School

3710 Dorisa Ave, Oakland, CA 94605 Phone: (510) 957-0570 Fax: (510) 957-0559

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