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Texas Tech University Child Development Research Center
Family Information Form
As you begin this questionnaire, we would like to remind you that the information you provide is
strictly confidential. The information is designed to assist directors and teachers in providing
care for your child while at the Child Development Research Center.
Today's date
Month
Day
____________________
Year
The Parents and Child
Name of child:
Gender
Nickname:
Date of birth ______________
Home Phone #
Address:
Parent’s name
Address (if different from above):
Highest Level Education:
Occupation:
Business Address:
Phone Number:
Parent’s name
Address (if different from above):
Highest Level Education:
Business Address:
Mother’s ethnic origin or race:
Occupation:
Phone Number:
Father's ethnic origin or race
What language(s) does the child speak at home?
Are other languages spoken at home? If so, what are they? ___________________________________________
How would you like to see your home language supported in the classroom?
Are there ways in which you would like to share your culture, family traditions, beliefs, and/or language with
children in the classroom?
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The Family
What are this child's living arrangements: (Check the most appropriate response)
Living with single parent (never married).
Living with single widowed parent.
Living with married or committed parents.
Living with remarried widowed parent.
Living with single divorced parent.
Living with relative other than parent.
Living with divorced parent and another adult.
Living with remarried divorced parent.
(relation to child ________________)
Other (Please describe)
If the child's parents are divorced is the non-residential parent remarried? Yes (name____________) No
Who usually takes care of this child and for how many waking hours each week? (Please list other child care,
babysitters, parents, other family members, and number of hours child is usually there each week).
_________________________ for
_________________________ for
___________ hours a week
___________ hours a week
Please list all children who live in the same house as the child and other children who are considered this child's
brothers and sisters (e.g., step brothers) even if they do not live in the same house.
Name
Sex
Age
Lives at
Relationship to child
home?
We would also like to know who else lives in the home besides the children listed above. Please list any other
relatives, boarders, etc. who live in the home.
Adult's Name
Sex
Age
Relationship to Child
Are there other adults who do not live in the house with the child but who are important to the child and with
whom he or she spends a good bit of time (for instance, a grandparent who lives nearby)?
Adult's Name
Sex
Age
Relationship to Child
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Developmental History
Child’s birthplace:
Delivery and Birth Conditions:
Length of Labor:
Type of Delivery:
Special Circumstances (breech, anoxia, etc.)
Apgar scores:
Birth weight:
Birth Length:
Child’s health at birth:
During the first 3 months:
Was child adopted?
yes
no If so, when?
How has adoption been interpreted to child?
Method of feeding
breast
Age at which solids begun
bottle
both
Approximate age at weaning
Methods of guidance/discipline used with child:
Child’s usual reaction:
Child’s usual response to separation from parents/family/friends:
Particular fears/anxieties expressed by child:
Recent experiences affecting child (move to new house, birth of sibling, death of pet, etc.):
Favorite indoor and outdoor activities:
Child’s most alert period of the day:
Child’s least alert period of the day:
Child’s responsibilities at home (dressing self, picking up toys, feeding pet, etc.):
Activities from which the child is prohibited:
Favorite foods:
Least liked foods:
Food child is not allowed to eat or drink:
Usual sleeping schedule:
Child sleeps:
in crib
in bed with others
alone in bed
in room with other children
in room alone
in room with parents
Usual toileting routine (if applicable):
Person who initiates toileting
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Procedure child expects/understands
Word child uses to indicate:
Toileting lapses:
Pets:
need to urinate:
need to defecate:
are infrequent
are occasional
are frequent
Name
___________________________
___________________________
___________________________
occur during the day
occur during the night
Kind
__________________________
___________________________
___________________________
What do you hope your child will gain from his/her experiences in the CDRC?
Is there any additional information about your child that would be helpful for the teacher to know?
What do you as a parent hope to gain from your association with the CDRC?
What particular concerns do you have about your child attending the CDRC?
Please list any hobbies, talents, or professional experience that you could share with the children
at school (cooking, sewing, woodworking, drama, electronics, medicine, etc.)
What are some ways that you would like to be involved in the CDRC:
Serve on a parent advisory committee
Help plan special center events
Help with fundraisers
Make classroom materials
Volunteer in the classroom
Assist with fieldtrips
Make and/or repair dramatic play clothes
Work in the CDRC garden
Help with playground repairs/maintenance
Help organize/catalog the library
Share family culture/traditions with the class (________________________________________)
Organize a parent support/reading group or parent meeting
Other? (_______________________________________________________________________)
Parent Signature
Date_________
Parent Signature
Date_________
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