Child Information Record | Preschool

Child Information Record Form

Session Attending:First Name: Middle Name: Last Name: Nickname: DOB: Age: Sex:Street Address: City: Zip Code: Home Phone: (Number you would like your child to learn)

Mailing Information: (if different from street address)

Mailing Address: Mailing City: Mailing Zip Code:

Mother's Information

Mother's Name: Mother's Occupation: Mother's Place of Employment: Mother's Place of Employment: Mother's Days and Hours of Employment: Mother's Telephone (Work): Mother's Telephone (Cell): Mother's Email Address:

Father's Information

Father's Name: Father's Occupation: Father's Place of Employment: Father's Place of Employment: Father's Days and Hours of Employment: Father's Telephone (Work): Father's Telephone (Cell): Father's Email Address:

Who should we call first if your child needs to be picked up early due to illness?

Name: Relationship: Phone:

Person(s) AUTHORIZED to pick up my child:

Second Person

Name: Relationship: Phone:

Third Person

Name: Relationship: Phone:

Fourth Person

Name: Relationship: Phone:

Fifth Person

Name: Relationship: Phone:

Person(s) who MAY NOT pick up my child:

First Person

Name: Relationship: Phone:

Second Person

Name: Relationship: Phone:

Medical Information:

Child's Physician: Child's Physician Phone: Child's Dentist: Child's Dentist Phone:

Please respond to the following questions by giving us as much background information as you can. We use this sheet to aid in observing and understanding your child.

Does your child have any recurring health problems? If yes, please explain:
Does your child have any special dietary considerations? If yes, please explain:
Does your child have any known allergies? (ie: food, seasonal, pet, etc.) How does the allergy manifest itself? (ie: asthma, runny nose, hives, etc.) Are your child's immunizations up to date?
Has your child experienced any recent toilet problems? If yes, please explain:
Do others have difficulty understanding your child's speech? If yes, please explain:
Does your child struggle in any of the following categories: sleeping, eating, dressing, toileting, siblings, following instructions, etc.
Are there any recent or upcoming events in your child's life that might affect his/her behavior? (ie: marriage, divorce, death, move, new baby, etc.) If yes, please explain:
Do you have any special concerns about how your child will approach preschool, such as aggression, anger, anxiety, hostility, extreme shyness, developmental concerns, or any specific fears? If yes, please explain:
How would you describe your child's personality/temperament?
How would you describe your child's relationship with other children?
Has your child been in a preschool or group child care before? If yes, what type of care?
Will your child be concurrently enrolled in another center? If yes, which one?
Do you have any personal concerns about placing your child in preschool?
What do you hope your child gains from his/her preschool experience?
Developmentally, what do you expect the preschool to provide your child?
Academically, how do you hope the preschool will prepare your child for kindergarten?
What first name do you want your child to learn to print?
Is your child left or right handed?
Does your child have any pets? (Type and name)

Please list your child's favorites:

Foods: Toy/Game: Hobbies: Color: Is there anything more you would like us to know about your child?

List the other children in your family:

First Sibling

Name: Age: Sex:

Second Sibling

Name: Age: Sex:

Third Sibling

Name: Age: Sex:

Fourth Sibling

Name: Age: Sex:

Fifth Sibling

Name: Age: Sex:

If your child will be absent please contact the preschool at (435) 586-9368.

Preschool tuition is $500.00 per semester for mornings (5 days per week) or $450.00 per semester for afternoons (4 days per week). Tuition can be paid at the beginning of each semester, or in four monthly installments of $125/$112.50. Please notify Cassie if you will be paying by the semester or monthly.

We encourage you to make payments online at suu.edu/ed/preschool under the "fees" tab. This option is preferable due to easier tracking of payments.

If you are unable to pay online, payments can also be made at the cashier's office located in the Sharwan Smith Rotunda, however the guardian must provide SUU Preschool with a receipt.

Monthly due dates: September 4, 2012 October 1, 2012 November 5, 2012 December 3, 2012 January 7, 2013 February 4, 2013 March 4, 2013 April 8, 2013