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Information Form
Please fill out the information completely.
Fields marked with a
*
are required.
*
Indicates required field
Child's Name
*
First
Last
Child's Nickname
*
Session
*
Session I (8:30 - 11:00 AM)
Session II (12:00 - 2:30 PM)
Age at Potty Training
*
Please list any siblings and their ages in parenthesis (…)
Sibling 1
*
Sibling 2
*
Sibling 3
*
Sibling 4
*
Please list any other family members living in household and their relationship in parenthesis (…)
Family Member 1
*
Family Member 3
*
Family Member 2
*
Family Member 4
*
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?
*
Before 6:00 AM
6:00 - 6:30 AM
6:30 - 7:00 AM
7:00 - 7:30 AM
7:30 - 8:00 AM
8:00 - 8:30 AM
8:30 - 9:00 AM
9:00 - 9:30 AM
9:30 - 10:00 AM
After 10:00 AM
Does your child nap?
*
Yes
No
What time does your child go to bed?
*
Before 6:00 PM
6:00 - 6:30 PM
6:30 - 7:00 PM
7:00 - 7:30 PM
7:30 - 8:00 PM
8:00 - 8:30 PM
8:30 - 9:00 PM
9:00 - 9:30 PM
9:30 - 10:00 PM
After 10:00 PM
If yes, when does your child nap?
*
What method(s) of behavior control do you use at home?
*
How does your child respond to this correction?
*
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?
*
Please checkmark (✓) the following skills your child has learned
*
Say his/her name
State his/her age
Count number/objects
Follow simple directions
Name/identify colors
Write name
Plays well with others
Name/identify shapes
States/knows birthday
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 checkmark (✓) any symptoms your child frequently experiences
*
Colds/runny nose
Earache
Sore throat
Stomach ache
Fever
Describe any other symptoms/illnesses your child experiences:
*
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.
I agree to the above Media Release statement
*
Yes
No
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I'm New
Families
College Students
Adults
Get Involved
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