Child and Family History Form

A Child and Family History form is required by DCFS and helps teachers to understand and best meet the needs of the children attending Cherry Preschool. The information you share helps us to understand and validate each child's experience. Cherry Preschool respects the diverse composition of its families and is committed to protecting each family's right to privacy. The information you provide is strictly confidential and will not be shared with any person, agency, or school without your written permission.

Child's Name(Required)

First Last

Name your child wants to be called at school(Required)

Date of birth(Required)

Which of the following best describes your child?(Required)

Asian or Pacific Islander

Black or African American

Hispanic or Latino

Native American or Native Alaskan

White or Caucasian

Multiracial or Biracial

Other

Please complete for all parents/guardians. Please mark fields N/A if not applicable:

Parent/Guardian #1(Required)

First Last

Parent/Guardian #1 - Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian #1 - Cell Phone(Required)

Parent/Guardian #1 - Email(Required)

Enter Email Confirm Email

Parent/Guardian #1 - Employer's Name(Required)

Parent/Guardian #1 - Occupation(Required)

Parent/Guardian #1 - Employer's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian #1 - Work Phone(Required)

Parent/Guardian #1 - Former Occupations, Interests, Hobbies(Required)

Does Parent/Guardian #1 share legal responsibility for the child with another Parent/Guardian?(Required)

Yes

Parent/Guardian #2(Required)

First Last

Does Parent/Guardian #2 reside at the same address as Parent/Guardian #1?(Required)

Yes

Parent/Guardian #2 - Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian #2 - Cell Phone(Required)

Parent/Guardian #2 - Email(Required)

Enter Email Confirm Email

Parent/Guardian #2 - Occupation(Required)

Parent/Guardian #2 - Employer's Name(Required)

Parent/Guardian #2 - Employer's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian #2 - Work Phone(Required)

Parent/Guardian #2 - Former Occupations, Interests, Hobbies(Required)

Does your child have any siblings?(Required)

Yes

Sibling #1 - Name(Required)

Date Of Birth(Required)

School/Grade(Required)

Add Sibling #2

Add sibling #2

Sibling #2 - Name

Date Of Birth

School/Grade

Add sibling #3

Sibling #3 - Name

Date Of Birth

School/Grade

Add sibling #4

Sibling #4 - Name

Date Of Birth

School/Grade

What lanuguages are spoken at home?(Required)

If parents are divorced or seprated, please share any important information regarding custody and living arrangements:

Please share any other family situations that would be helpful for your child's teacher to know: (e.g:adoption of child/sibling, separation/divorce, blended family, recent/pending move, recent death/loss, foster care, etc)

Are there any classroom activities that your child may not participate in due to your families religious beliefs? (e.g.: music, dancing, snacks, birthday celebrations, etc.)

Does your child have a regular caregiver?(Required)

Yes

How many days of the week and how many hours per day?(Required)

Does your child have a sibling with an identified developmental delay or disability?(Required)

Yes

Please explain:(Required)

Was your child a full-term baby?(Required)

Yes

If not, how many weeks?(Required)

Are there any special factors concerning pregnancy or delivery. (Answer in terms of biological/birth parent if your child joined your family through adoption or is in your foster care.)(Required)

Yes

Please describe.(Required)

Are there any special circumstances in your child's early development that we should be aware of (e.g.: extensive hospitalization, prolonged separaton from primary caregiver, change of custody.)(Required)

Yes

Please describe.(Required)

Does your child receive support service/therapies in any area of development or have any special needs that have been identified (i.e.:speech and/or language delays; physical disabilities; developmental delays; ,motor or sensory integration issues; social/emotional/behavioral difficulties)?(Required)

Yes

Please explain.(Required)

My child has non-food-based allergies (e.g. havy fever, pet dander, dust, mold, etc)(Required)

Yes

Please explain:(Required)

My child has non-medical dietary restrictions (i.e.: religious or parental preference, kosher, vegetarian, vegan, etc.)(Required)

Yes

Please explain:(Required)

IF YOU CHECK THE BOX FOR ANY OF THE FOLLOWING, YOU WILL BE SENT AN ADDITIONAL ALLERGY/MEDICAL PACKET THAT MUST BE COMPLETED BY BOTH THE PARENT/GUARDIAN & YOUR CHILD'S PHYSICIAN PRIOR TO YOUR CHILD'S FIRST DAY

Untitled

My child has asthma

My child has food allergies that require a special diet

My child has a serious medical condition that may require ,monitoring or special treatment at school(e.g. diabetes, cancer, cystic fibrosis, seizure disorder, etc.)

My child takes medicine that might have to be administered at school

BEHAVIOR AND DISCIPLINE

What do you see as your child's strengths?(Required)

What activities does your child like to do most?(Required)

What do you find is the most difficult thing about your child's behavior to manage?(Required)

How do you think your child will handle separation issues at the beginning of the school year?(Required)

Please descibe any specific situations in which your child becomes tense, afraid, or angry.(Required)

In general, how do you limit or discipline your child?(Required)

Is your child toilet trained?(Required)

Yes

Please share any information you would like the school to know regarding your child's toilet training you would like the teacher to know:

Does your child nap?(Required)

Yes

Sometimes

What hours?

What is your child's bedtime?(Required)

Please share any other information you would like the school to know regarding your child's sleep schedule:

What do you hope your child will gain from this coming year at Cherry Preschool? Please share your goals for your child:(Required)

Has your child had any previous experience with playgroups, preschool, day care, camp, etc.?(Required)

Yes

Group Experience #1(Required)

When(Required)

Was parent/guardian included in experience?(Required)

Yes

Group Experience #2

When

Was parent/guardian included in experience?

Yes

Group Experience #3

When

Was parent/guardian included in experience?

Yes

Are you a new Cherry Preschool family?(Required)

Yes

How did you learn about Cherry Preschool?(Required)

Friend/Colleague

Social Media

Search Engine (e.g.; Google)

Pediatrician

Therapist

Other

Name of friend or colleague who referred you(Required)

Which social media platform? Instagram or Facebook(Required)

Name of parent/guardian completing form(Required)

First Last

Signature of parent/guardian completing form(Required)