SCHOOLHOUSE ADVENTURES PRESCHOOL CHILD INFORMATION/PERSONAL HISTORY FORM

33325 Sears Boulevard – Wildwood, IL 60030

Phone (847)223-7275 Fax (847)223-2820

Name of Child:_________________________________________ Sex:______

Child’s Nickname:_________________________ Date of Birth:______________________________

Child’s Home Address:____________________________________________________________________

Child’s Home Phone:____________________ Child’s Physician:_______________________________

Physician Address:__________________________________ Physician’s Phone:_____________________

Class registering for: _____Mon & Wed A.M. _____Mon, Wed, Fri P.M.(Pre-K)

PARENT INFORMATION

Mother’s Name:_______________________________________ Address:__________________________________________________________________________________

Home Phone:__________________________ Cell Phone:__________________________

Mother’s Employer:_____________________________________ Work Phone:_______________________

Hours:_________________________

Father’s Name:_______________________________________ Address:__________________________________________________________________________________

Home Phone:__________________________ Cell Phone:__________________________

Father’s Employer:_____________________________________ Work Phone:_______________________

Hours:_________________________

FAMILY INFORMATION

Names and ages of siblings: Please indicate if they are currently residing with the child.

1._________________________________________ 2.___________________________________________

3._________________________________________ 4.___________________________________________

Please list anyone else residing with child and their relationship, if applicable.

1._________________________________________ 2____________________________________________

3._________________________________________ 4.___________________________________________

Types of pets and names:

1._________________________________________ 2._________________________________________

3._________________________________________ 4._________________________________________

EMERGENCY INFORMATION

Persons authorized to pick-up child: Please indicate their relationship to child.

1._______________________________________________ Phone:_________________________________

2._______________________________________________ Phone:_________________________________

3._______________________________________________ Phone:_________________________________

Emergency Release Numbers:

1._______________________________________________ Phone:_________________________________

2._______________________________________________ Phone:_________________________________

Persons who MAY NOT pick-up child:

1._______________________________________________ Phone:_________________________________

2._______________________________________________ Phone:_________________________________

Please list a working phone number at which you may be reached early in the morning should school be cancelled due to weather or other issues with little notice:___________________________________________

PERSONAL HISTORY

Are there any medical issues staff should be aware of? (Allergies, physical limitations, etc.) Please explain:

__________________________________________________________________________________________

__________________________________________________________________________________________

Does child have any fears?____________________________________________________________________

Has child had any previous preschool background? If so, where was it? Please explain whether or not it was a positive or negative experience?

__________________________________________________________________________________________

__________________________________________________________________________________________

How does child react in a group of peers in the following situations, if applicable:

Free Play__________________________________ Circle Time___________________________________

Craft Time_________________________ High-Energy Group Activities____________________________

Does child favor: Right Hand_____ Left Hand_____ Not Clear Yet_____

Is child’s home bilingual? Yes_____ No_____ If yes, what languages?___________________________

Please list a few of child’s interests or hobbies: (Dinosaurs, bike-riding, etc.)

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please list three goals you would like to achieve through participation in Schoolhouse Adventures Preschool:

1.________________________________________________________________________________________
2.________________________________________________________________________________________

3.________________________________________________________________________________________

Is there anything else you would like to share with staff regarding personality or habits that will help us better understand the child, and further enhance their preschool experience?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________