Name: Basic Judaism
Start: 2019-03-26T19:30:00-04:00
End: 2019-03-26T21:00:00-04:00
Location: Congregation Beth Elohim

Early Childhood Intake Form

Child's Name*

First Last

Date of Birth*

Gender*

Address*

Street Address Address Line 2 City State ZIP Code

With Whom Does the Child Live?*

Parents' Marital Status*

Please describe custody agreement.*

Parent One Information

Parent Name*

First Last

Parent Date of Birth*

Primary Email*

Cell Phone*

Occupation*

Employer*

Work Phone*

Work Address*

Street Address Address Line 2 City State ZIP Code

Parent Two Information

Parent Two Name

First Last

Date of Birth

Primary Email

Cell Phone

Occupation

Employer

Work Phone

Work Address

Street Address Address Line 2 City State ZIP Code

Siblings: (Please indicate if half or step siblings)

Name

First Last

Gender

Age

School

Name

First Last

Gender

Age

School

Name

First Last

Gender

Age

School

If any of the above are half or step siblings, with whom do they live?

How often does child see them?

Has your child had any previous school or playgroup experience?

Name of School

Dates Attended

Describe your child's adjustment to previous school.

Do any other adults care for your child?*

Who and how often?*

What is your child's reaction to your leaving?*

How does s/he get along with other adults?*

What kind of activities does s/he enjoy?*

How does your child react to a new situation?*

How do you discipline your child?*

What kinds of things upset your child or make her/him angry? Any special fears (animals, the dark, strangers, clowns, etc.)?*

How do you reassure your child?*

How would you describe your child? (Active, shy, inquisitive, quiet, easily upset, cheerful, demanding, etc.)*

How does your child sleep? Describe any special bedtime/naptime routines.*

Does s/he sleep through the night?*

Does s/he have own room or share?*

Does s/he sleep in a crib or a bed?*

What time does your child usually go to bed?*

: HH

MM

When does s/he nap?*

: HH

MM

Is your child completely toilet-trained?*

What words does s/he use for urination?*

Bowel movement?*

Describe eating habits.*

Has your child had any serious illness or accident and/or hospital experience? Any childhood diseases?*

Does your child have any allergies?*

Please describe symptoms and actions we should take.*

Please Note

In order to keep or administer any emergency medication (including Benadryl, epipen, or nebulizer) our school is required to have instructions signed by your child's doctor. Please call the ECC office to arrange to have the appropriate forms sent to you.

Please describe any problems during pregnancy and/or birth.

Developmental Milestones

At what age did your child start to pull self up?*

Crawl?*

Walk?*

Speak single words?*

Speak in two or three word phrases?*

Speak in complete sentences?*

Become toilet trained?*

Does your child have any special needs that you wish to make us aware of?*

Please describe.*

Please indicate any special education services your child will receive during the school year. We find that it is highly beneficial to a child's progress to promote communication between classroom teachers and special educators. One of your child's teachers will contact you for permission to speak with your child's special educators. If you have any questions or concerns about this collaboration, please call the ECC office.

Is your child adopted?*

Does s/he know?*

Please explain anything else special about your child that would be helpful for us to know.

What do you expect this program to provide for your child?*

What do you expect this program to provide for you?*

How do you see yourself participating in our program? Do you have any special skills or hobbies?*

Are you a member of Congregation Beth Elohim?*

How did you first hear about our Early Childhood program?*

I/We have received a copy of Congregation Beth Elohim Early Childhood Center's Parent Handbook. I/We have read and agree to abide by the policies and procedures as stated in the Parent Handbook.

Signed*

Date*

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