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Dublin Elementary Kindergarten Form
Thank you for your help in carefully completing this questionnaire. This information helps us with placement of students and to provide success for your child, you, and your child's teacher. We appreciate your partnership with us at Dublin Elementary.
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Welcome to Dublin Elementary School!
Child's Name: Last, First
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Your answer
Child's Gender
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Your answer
Child's Birthdate
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MM
/
DD
/
YYYY
Mother's (or guardian) name
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Your answer
Father's (or guardian) name
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Your answer
Child resides with
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Both parents
Mom
Dad
Other:
Best email to reach you? Please label each email address.
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Your answer
Best phone number to reach you? Please label each phone number.
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Your answer
Home Address
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Your answer
What is your child's position in the family? Example: first of two children.
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Your answer
Please list any other children in the family - ages, grade level, and school(s) they attend. Please enter N/A if there are no other children.
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Your answer
Has your child had an preschool experience outside of daycare?
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Yes
No
What ages did you child attend preschool?
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3
4
Both
Did not attend preschool. Only attended daycare.
Did not attend preschool or daycare.
Name of preschool your child attended? Please enter N/A if they did not attend preschool.
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Your answer
Name of daycare your child attended? Please enter N/A if they did not attend daycare.
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Your answer
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.
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Your answer
Has your child had difficulty with ear infections?
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Yes
No
Does your child have good bowel & bladder control?
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Yes
No
Does your child currently have any health problems? If yes, please explain. If no, write none.
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Your answer
Is your child on medication regularly (including inhalers)? If none, answer none. If yes, please list the medication and purpose for taking.
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Your answer
Approximately how many hours a day do you allow for television viewing/video gaming?
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Your answer
Has your child experienced any fine motor/physical difficulties? If no, mark none. If yes, please explain.
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Your answer
Has your child received an intervention program such as:
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Speech
Early Childhood Special Education
Occupational Therapy
None
Other:
Location and dates of intervention (per above question)
Option 1
Clear selection
In your family, is there a history of learning or speech problems? If yes, please explain below.
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Yes
No
Please explain (per above question)
Your answer
Do you have any developmental concerns about your child? If no, mark none. If yes, please explain.
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Your answer
Is there any home situation that might affect your child and his/her adjustment to school? If no, mark none. If yes, please explain.
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Your answer
To what type of learning environment does your child best respond?
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Your answer
What characteristics do you observe in your child's personality and learning style?
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Your answer
What is the primary language spoken in your home?
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Your answer
Are there other languages spoken fluently other than English in your home? If yes, please explain below.
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Yes
No
Language(s) spoken fluently in your home?
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Your answer
(Optional) Do you celebrate holidays in your home?
Yes
No
Clear selection
(Optional) Which holidays do you celebrate?
Option 1
Clear selection
For this next section, please help us get to know your child. This information will help us determine your child's needs and successes. You will have an opportunity to include more information at the end of this survey.
My child can SAY:
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His/her first name
His/her age
His/her birthday
Name of parent(s) or guardian(s)
The alphabet
Ask for help
None of the above
Required
My child can take care of personal needs:
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Take care of ALL bathroom needs
Button/snap pants
Zip jacket
Tie shoes
None of the above
Required
My child can recognize:
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First name
Last name
Letters in first and last name
Letters of the alphabet (out of order, upper and lowercase)
8 basic colors (red, yellow, orange, green, blue, black, purple, brown)
4 basic shapes (circle, square, rectangle, triangle)
Numerals 1-10
Parts of a book (front, back, pictures, words)
None of the above
Required
My child has these fine motor skills:
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Write first and last name
Write the alphabet
Use scissors correctly
Hold a pencil correctly
Use crayons correctly
Use a glue stick
Use a computer mouse
Draw the four basic shapes (circle, square, rectangle, triangle)
None of the above
Required
My child can:
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Show position (over, under, below, above, beside, behind)
Count to 20
Identify left and right
Point to appropriate body parts (head, shoulders, arms, legs, etc.)
None of the above
Required
Do you read to your child?
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Yes
No
How often do you read to your child?
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Your answer
Can your child separate from parents/guardians without tears?
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Yes
No
Does your child sleep well (8-10 hours/night)?
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Yes
No
Does your child play well with other children?
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Yes
No
Does your child talk easily with adults?
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Yes
No
Does your child seem coordinated?
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Yes
No
Does your child have a good attention span?
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Yes
No
Does your child become distracted easily?
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Yes
No
Does your child accept the word "no"?
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Yes
No
What method of discipline seems to work best for your child?
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Your answer
Is there anything else you feel we should know about your child to help us in understanding him/her better?
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Your answer
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