Special Needs Preschool Intake Form

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Thank you for your interest in the Canal Winchester Preschool Program. Please complete this form if you have concerns with your child's development. When finished, please be sure to click the submit button at the bottom of the application. This application will be time stamped.

If you have any questions, please contact Maleea Anderson, Preschool Coordinator, at 614-920-2757.

Completing this form will help the District collect necessary information in order to appropriately address your concerns. Following the completion of this form, the Preschool Coordinator will contact you to schedule an appointment to discuss your concerns further and to share the next steps in the process. Thank you!

Email *

Application Date: *

YYYY

Child's First and Last Name *

Form completed by: *

Relationship to child: *

Mother

Father

Guardian

Foster Parent

What name does your child respond to? Nickname: (if the child goes by a different name) *

Child's Date of Birth (mm/dd/yyyy) *

Child MUST be at least 3 years old to be considered for the evaluation process.

Please enter age of child: (MUST be 3 years old at the time of completing this application to be considered for the evaluation process.) HELP ME GROW families, please disregard and enter N/A. *

Child is *

Male

Female

Address: Please enter your address on the line below. *

(You and your child must reside within the Canal Winchester Local School District)

City *

Zipcode *

Mother/Guardian's Name *

Home Phone Number *

Cell Phone Number *

Email Address *

Father/Guardian's Name *

Home Phone Number *

Cell Phone Number *

Email Address *

Who else besides the child lives in the home? (siblings, other family members). *

Describe any unique family circumstances that have a significant impact on this child's development. Please also include foster care or guardianship information if applicable. *

Do you suspect any problems with your child's development? *

Yes

Not sure

Presenting problem - Check the area(s) which are of concern: *

I have no concerns

Health problems

Difficulties separating from parent/caregivers

Suspected Autism

Abuse

Eating

Dressing

Emotional difficulties

Problems with peers

Receptive communication (How your child understands language)

Expressive communication (How your child communicates their wants and needs)

Cognition

Fine Motor

Gross Motor

Play

Heightened Activity Level

Required

Is there a different languages spoken in the home? *

YES

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