Oakley Park Kindergarten Questionnaire
Thank you for your time in carefully completing this questionnaire.
Sign in to Google to save your progress. Learn more
Child's Name: Last, First *
Child's Birthdate *
MM
/
DD
/
YYYY
Has your child had a preschool experience outside of daycare? *
What ages did your child attend preschool? *
Name of preschool school  your child attended? (please enter N/A if they did not attend preschool) *
Name of daycare your child attended? (please enter N/A if they did not attended daycare) *
Best email to reach you? *
Best phone number to reach you? *
Home Address *
Mother's (or female guardian) Name *
Mother's (or female guardian) Occupation
Father's (or male guardian) Name *
Father's (or male guardians) Occupation
Marital Status *
Child resides with *
Please list any other children in the family, their ages, grade level and school(s) they attend. *
Does your child have medically diagnosed allergies (such as peanut, tree nut, gluten or dairy, etc.)? If so, please list them. Does your child react if the allergen is airborne or ingested? If your child doesn't have medically diagnosed allergies, please put N/A. *
Does your child currently have any health problems? If yes, please explain. If no, write none. * *
Is your child on medication regularly (including inhalers)? If none, answer none. If yes, please list the medication and purpose for taking. * *
Has your child experienced any fine motor/physical difficulties? If no, mark none. If yes, please explain. * *
Has your child received an intervention program such as: *
Location and dates of intervention (per above question)
In your family, is there a history of learning or speech problems? If yes, please explain below. * *
Please explain *
What is the primary language spoken in your home? *
Are there other languages spoken fluently other than English in your home? If yes, please explain below. * *
Language(s) spoken fluently in your home? *
Do you celebrate holidays in your home? *
Which holidays do you celebrate? If no, put none *
Do you read to your child? *
How often do you read to your child?
Has your child had experiences with crayons? *
Has your child had experiences with scissors? *
Has your child had experiences with glue/glues sticks? *
Has your child had experiences with using a computer mouse? *
Can your child use the bathroom unassisted? *
Does your child have good bowel & bladder control? *
Can your child manage clothing independently? *
Can your child separate from parents/guardians without tears? *
Does your child sleep well (8-10 hours/night)? *
Does your child play well with other children? *
Does your child talk easily with adults? *
Does your child seem coordinated? *
Does your child have a good attention span? *
Does your child become distracted easily? *
Does your child accept the word "no"? *
What method of discipline seems to work best for your child? *
Is there anything else you feel we should know about your child to help us in understanding him/her better? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Walled Lake Consolidated Schools. Report Abuse
Google Forms