Preschool Screening Questionnaire MPGS 2020-2021 School Year

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Please complete the following questions to your best ability. At MPGS, we use a needs-based eligibility checklist when determining placement in the Preschool program. Due to the COVID stay at home orders, we are unable to hold face-to-face screenings at this time, and will rely on information from this survey to begin placement for the 2020-2021 school year. Data is confidential, and will be used only for placement in the program and for school record purposes. This questionnaire must be submitted for your child to be considered for eligibility. You will be contacted by our Preschool/Early Childhood team once class lists and waitlist are compiled. Thank you for taking the time to complete this survey, and for your interest in the MPGS Preschool program!

Email *

Please list your child's name and birthdate: *

Parent/Guardian Information: Names and Address(es) *

Parent/Guardian Phone number(s) *

Please check any of the following that apply to your family/child:

Child is currently, or was previously in foster care

Family receives WIC, SNAP, TANF, or Medicaid

DCFS involvement with the family (includes current or past cases)

History of drug or alcohol abuse in the family

Chronic illness

Frequent tantrums/Impulsive behavior

Separation Anxiety

Speech Delay/Speech difficult to understand

Experience in a daycare setting, or has had regular interaction with same-aged peers

Difficulty adapting to change/anxiety

Child has difficulty sleeping

Early Intervention Service or Documented Disability

Death in immediate family

Lives with caregiver other than parent

Teen parent at birth of first child

Single parent

Low birth weight or failure to thrive

English Language Learner/language other than English spoken in home

Active military parent

Family member incarcerated

Parent/caregiver did not complete high school/No GED

Immediate family member in special education

Umemployment in household (Covid Related)

Umemployment in household (NOT Covid Related)

Currently homeless

History of homelessness

Sensory Concerns (child avoids loud noises, certain foods/clothing due to textures etc.)

My child is able to identify the following:

Some or all colors

Some or all shapes

Basic body parts

Can name various animals and common objects

Uses controlled strokes when coloring or writing

Is able to manipulate small toys/objects with fingers

Did you have a difficult pregnancy or delivery with your child? If yes, please describe:

Has your child received Early Intervention Services or been diagnosed with a disability? If yes, please list:

Do you have any concerns with your child's vision or hearing? If so, please list:

List any previous surgeries and child's approximate age at the time of the surgery:

Do you have any health concerns for your child? Ex. tubes, ear infections, asthma, other illnesses. If yes, please list.

Do you have any concerns regarding your child reaching developmental milestones at the appropriate age? (Speech, Motor Skills, Social Skills, etc) If yes, please list:

Please list any other concerns you would like to share with the Preschool/Early Childhood team regarding your child:

If your child is placed in the Preschool/EC program at MPGS for the 2020-2021 school year, do you have a preference in morning or afternoon preschool session? We will try our best to accommodate parent preferences, but it is not a guarantee.

No Preference

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