San Francisco Unified School District Child Development Program
Child/Family Personal Information
Welcome to the Child Development Program! This questionnaire is intended to collect information
from you and your family in order for us to get to know your child and plan a program that will meet
his/her interests and needs.
(The information contained in this form is CONFIDENTIAL and will only be made available to the
appropriate staff.)
(PLEASE PRINT)
Center: ________________________________________________ Date: ________________________
Child’s Name: ______________________________ DOB: ________________ M/F: _______________
Parent/Guardian Name: ___________________________ Phone Number: ______________________
Parent/Guardian Name: ___________________________ Phone Number: ______________________
1. About your Child
a) List previous experience(s) your child has had with a full-time baby-sitter, relatives, nursery
school, or other child care agency.
b) Who lives in your home with you and your child?
c) Are there other important adults in your child’s life? If so, does your child have any contact with
her/him?
d) Does your child have siblings? If so, what are their names and ages?
e) Describe your child’s personality:
f) What do you enjoy doing together with your child?
g) Describe your child’s favorite activity.
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h) How are conflicts handled at home with your child? (Such as tantrums, discipline issues,
problems with brother and sisters, etc.)
i) What language(s) does your child speak?
j) Is your child able to express his/her needs verbally? Are you able to understand your child?
Are other people able to understand him/her easily?
k) Does your child play with any other children?
l) Does your child have any particular fears that we need to be aware of?
m) How does your child handle change/transitions?
n) What helps to soothe your child when s/he is upset?
o) Are there any toys, blankets, etc. that would help your child feel more secure in a new place?
p) How much TV does your child watch every day? Which programs?
q) Is there any other information or concerns you have about your child or family that would be
important for us to know?
2. Child’s Eating Habits
a. What are your child’s favorite foods?
b. Are any foods not eaten by your child?
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c. How do you rate your child’s appetite? ____Good ____Fair ____Poor
3. Toilet Habits (Omit for School Age child)
a. Words your child uses for toileting:
b. When did your child learn to always use the toilet?
c. Does your child experience:
Bedwetting _______ Frequent urination ______ Constipation _____ Diarrhea ______
If so, please explain:
4. Sleeping Habits
a. What time does your child go to sleep? What is the bedtime routine?
b. What time does your child wake up?
c. Does your child nap?
About what time usually?
d. Is there anything we should know to help your child sleep at nap time?
5. Child’s Health
a. Does your child have:
Asthma
Yes___
No___
Food allergies
Yes___
No___
Medication allergies Yes___
No___
Other allergies
Yes___
No___
Seizures
Yes___
No___
Other medical conditions______________________
Please explain:
b. Does your child experience:
Recurrent rash_____ Continuous runny nose_____ Ear aches_____
Frequent colds_____ Fainting_____
Hearing loss ____
Stuttering
_____ Nose bleeds_____
Speech difficulty_____
Tooth issues _____ Heart condition_____
Vision difficulty_____
Stomach pain _____ Tires easily_____
Other issues ________________
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Please explain:
6.
School Experiences
a. What are your hopes for your child in preschool?
b. Has your child ever been evaluated for Special Education services?
Yes _____
No _____
Does your child currently have an I.E.P.?
Yes _____
No _____
c. How would you like to participate in our school community?
Volunteering___
Getting involved in Parent-Teacher Committees___
Attending Parent Education Workshops___
Other_____________________________________
Please explain:
d. Are there any other questions or concerns we can address; or additional information you
would like us to know?
____________________________________________________________________________________
Parent/Guardian Signature
Date
____________________________________________________________________________________
Parent/Guardian Signature
Date
Thank you for taking the time to share with us such valuable information about your child and your
family. We look forward to working with you!
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