Information Form

Does your child have special fears? *

Please list any food or drink ingredients your child should not have. *

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

What languages, if any, are spoken at home other than English? *

What time does your child wake up? *

Does your child nap? *

What time does your child go to bed? *

If yes, when does your child nap? *

What are some of your child’s favorite activities? *

Has your child gone to preschool or daycare before? (If yes, where?) *

What would you like to be included in your child’s preschool program? *

Age when he/she began walking *

Age when he/she became potty trained *

Age when he/she wiped self after potty *

Please explain any stressful experiences, if applicable, which may affect your child's behavior (divorce, death, family illness, etc) *

Please list any allergies, if applicable, that affect your child and describe the reaction symptoms of which we should be aware *

MEDIA RELEASE: I grant to Kiddie Kampus, Upland United Methodist Church and its children’s ministry, employees, and volunteers the right to take photographs, video, and/or electronic images of any member of my family in the children’s ministry environment. I authorize the aforementioned entities to copyright, use, and publish (i.e. Facebook) the photographs, video, and/or electronic images in print and/or electronically—with or without our names—for any lawful purpose to highlight and promote Kiddie Kampus, Upland United Methodist Church and its children’s ministry.

Information Form

201 N. 8th Street, Upland, IN 46989 | (765) 998-2985