(This applies to children who turn 5 years old after September 1)
Date:___________________________________
Name of Child:________________________________ Birthdate:___________________
Parent/Guardian Name(s):___________________________________________________
Home Address:_________________________________ Home Phone: ___________________
_________________________________ Work Phone: ___________________
Site your child would be attending: _____Lone Rock _____Plain
_____Spring Green _____Arena
Please answer the following questions as accurately as you can.
1. Describe your child's developmental history (age your child began to walk, talk, was toilet trained, used longer sentences).
2. Describe your child's health history (any serious injury, illness, hospitalization, birthing problems, medications).
3. Can your child:
_____ Button? _____ Snap? _____ Zip? _____ Tie?
4. Can your child dress himself/herself?
5. Does your child enjoy:
_____ Coloring? _____ Pasting? _____ Cutting?
6. Does your child often have ideas which are very original in one or more areas (block play, free activities, art)? If yes, give an example.
7. Please comment on your child's favorite:
Indoor activities:
Outdoor activities:
Television programs:
Social activities:
8. Will your child listen to a story for 10 minutes?
9. How long (minutes) will your child work or play independently?
10. List the books you have read to your child during the past month.
11. Does your child prefer to play with:
_____ Children of the same age? _____ Older children?
_____ Younger children? _____ Adults?
_____ Solitary games/activities?
12. Do you see evidence of your child having an unusually good memory/memorizes rapidly? Give examples.
13. Does your child have a high level of energy/seems to need little sleep?
14. Is your child alert, keenly observant, quick to respond, and curious about many activities and places? Give examples.
15. Does your child prefer complicated games, puzzles?
Does he/she like jokes and tricks?
Does he/she like make believe, made-up games, and imaginary friends?
16. About how often does your child have an opportunity to visit a library or museum?
17. About how often does your child have an opportunity to play with other children or participate in group activities with other children?
18. Is your child able to get along with other children while not under adult supervision?
19. Has your child attended day care, nursery school, or other types of pre-school programs? Please list dates and places.
20. Can your child follow rules, take turns, share, and play cooperatively?
21. What role does your child take when playing with a group of children?
_____Leader _____Follower
_____Parallel play _____Tries to influence others
22. Is your child able to draw rather than scribble?
23. Does your child know his/her full name, telephone number, and address?
24. Does your child know all the letters of the alphabet and their sounds? Is your child beginning to read?
25. Can your child:
_____ Hop on one foot? _____ Throw?
_____ Skip? _____ Catch a ball?
26. Has your child been involved in any activities which would help to develop the following areas? Please list those activities.
Large muscles (dance, swimming, soccer, karate):
Small muscles (painting, crafts, arts):
Listening skills (such as library story hour):
27. How well does your child follow directions at home?
28. What do you consider your child's strong points?
29. What do you consider your child's weaker areas?
30. Has your child expressed an interest in attending school?
31. Please indicate any other information which you feel will aid in assessing your child's readiness for kindergarten:
APPROVED: March 31, 1997
12/21/2004 pw