Bearcamp Valley School & Children’s Center
PUPIL DATA SHEET
Date of Enrollment: ______________________
Name of Child(Last, First, Middle):
Primary Mailing Address (street, city, state, zip)
Date of Birth ( mm/dd/yy)
Town of Residence:
Place of Birth: (City/Town & State)
Child lives with: ____Mother ___ Father ____Both parents _____ Shared Custody ____ Guardian
Parent/Guardian Contact #1 Name:
Mailing Address:
Town, State, Zip:
Town of Residence:
Ph 1:
Ph 2:
Email address:
Ph 3:
___ Yes, add me to your email list for program news & notices
Highest level of education/training completed:
Marital Status: ___ single ___ married ___ separated ___ divorced
Occupation/Place of Business: __________________________________________________
Typical Work Hours:
year-round _______________ seasonal _________________
Parent/Guardian Contact #2 Name:
Mailing Address:
Town, State, Zip:
Town of Residence:
Ph 1:
Ph 2:
Ph 3:
Email address: ___________________________________________
___ Yes, add me to your email list for program news & notices
Highest level of education/training completed:
Marital Status: ___ single ___ married ___ separated ___ divorced
Occupation/Place of Business: __________________________________________________
Typical Work Hours:
year-round _______________ seasonal _________________
Siblings: (name/s)
Other household members not listed above:
HEALTH HISTORY
Did child’s mother have a difficult pregnancy?
Age/s ,Grade/s:
Did child’s mother have a difficult birth?
Was your child’s birth on time / near due date? ____yes ___ no ____; Birth Weight:
Was your child ever hospitalized or had a prolonged illness: ____yes ___ no ; describe briefly
Toilet Habits:
___ independently uses toilet ___ daytime toilet trained ___ nighttime toilet trained ___ bedwetting
Chronic Health Concerns:
Allergies: ____________________________________________________________________
Susceptible to frequent: ___ colds ___sore throats ___ earaches ___ nose bleed Other:
Medication: Does your child take any medication? ___ yes ___ no; Name of Medication:
Social Habits:
What are your child’s special interests? ____________________________Favorite type of toy? ____________
Has your child had opportunities to play much with other children? __________________________________
Prefers indoor or outdoor play? _________________Prefers interaction with ___children ___ adults ___ both
Play Habits: I would describe my child’s play as
___ Active ___ Gentle ___Destructive ___Thoughtful ___ Quiet ___Energetic ___ Noisy
___ Self-Initiated ___Rough ___Aggressive ___Solitary ___ Dependent on adult direction
Challenges in play? (hitting, biting, spitting, pushing)
How does your child react to animals? _____________________________________________
Does your child have a household pet? __yes __ no; type of pet? ______________________
Name of pet?
Does your child have an imaginary “friend” or pet? ___yes ___no Name
Sleep Habits: How many hours per night does your child typically sleep? _____________
Does your child take naps? ___ yes ___ no Problems with sleeping? ___________________ Nightmares?
Appetite and Nutrition Habits: Describe your child’s appetite __________________________________
Favorite food: ________________Least favorite food _______________________________
Special dietary restrictions/concerns:
How much help is needed with dressing/undressing?
Family Discipline Style:
Parent/Guardian 1 ___________________ Approach to discipline:
Parent/Guardian 2 ___________________ Approach to discipline:
How does your child show anger?
…frustration?
…anxiety?