Student Information

Child's Name:

Birthday:

Gender: select female male

Current School:

Person Completing Form:

Person Completing Form Email:

Relationship to Applicant:

Questions

1. Please list five words that you would use to describe your child.
   
2. Describe your child’s favorite things to do and/or special interests.
   
3. What are child’s favorite foods? Would you describe your child as a “picky eater”? Any food allergies?
   
4. What helps your child feel comfortable? (ex - a special toy or blanket)
   
5. Describe any special circumstances/health problems which have affected your child’s development or performance in school. (For example, severe allergies, illness, ear infections, learning or attention difficulties, frequent moves, etc.)
   
6. Does your child take any medications on a regular basis? Please explain.
   
7. Are there any circumstances that has or may have an impact on your child (i.e. loss of a loved one, recent move, new baby, divorce)
   
8. Does your child have any significant fears or anxiety issues (i.e. fear of bugs, loud noises, etc.)
   
9. Describe your child’s reaction to and behavior in a new or unfamiliar setting.
   
10. Describe any developmental or academic screenings your child has received (hearing, vision, neurological, speech, reading, math, etc.)
    
11. If your child is currently enrolled in a preschool program, please describe the setting and how often the child attends.
    
12. Why are you interested in enrolling your child at Cedar Creek?