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ECC Student/Family Information Form

We designed this form to learn more about you, your child and your family. Please answer the questions as thoughtfully as possible. The information you provide will not only help us get to know you and your child, but it will also help us to create a nurturing environment and engaging opportunities for him/her. The questions we ask are not meant to make you feel uncomfortable in any way. You may leave blank spaces, if you do not wish to answer a question. There is no right or wrong answer and all information you share will be kept confidential (it is shared with classroom teachers and school director). Our hope is that by getting to know your family, we may join you in the care of your child. Thank you for taking the time to complete this form.

* Child's Full Name

Date of Birth

Home Address

Home Phone Number

Parent 1 Name

Parent 1 Cell Phone Number

Parent 1 Occupation

Parent 1 Business Phone Number

Parent 1 Email Address

Parent 2 Name

Parent 2 Cell Phone Number

Parent 2 Occupation

Parent 2 Email Address

School District

Your Family:

Sibling(s) Name(s) and Age(s)

Who lives in your home?

Do you speak any languages other than English in your home?

How do you discipline your child?

Do you celebrate holidays or have other family traditions? How do you mark these special occasions?

Have there been any major changes in your family life within the past year (new home, new job, divorce, illness, death, birth, etc.)?

Do you have any special skills, talents, hobbies (work-related or otherwise)? Would you be willing to share these in the classroom?

Your Child:

Nickname/What does your child prefer to be called?

Please describe your child's temperament. What is unique about your child?

What goals, hopes or dreams do you have for your child this year?

What are some of your child's favorite things to do? (favorite books, toys, activities, ect.)

What are some of their least favorite things?

Is s/he attached to a favorite toy or object? Does it have a special name? When does s/he use it?

Does your child have any fears? If so, what?

What helps to reassure him/her?

Does your child have particular sensitivities (for example: loud noises, different textures, cold or hot weather)?

How is your child comforted when angry or upset?

Important changes in your child's life (i.e. moving, family illness, parent teruning to work, change in child-care arrangements, new baby, pregnancy, death, etc.)

Has your child completed toilet learning? If yes, at what age? If no, have you started toilet teaching, and when? How does s/he indicate his/her need to use the toilet?

Has your child attended any other school, daycare, play group? If so, where?

Does your child have any special needs or development concerns - diagnosed or suspected?

Has your child ever been evaluated by any school district or outside agency? If yes, what is the name of the school district or outside agency?

Is your child receiving any special services?

Is there anything that you wish to share about your child's development?

Describe your child's use of language

At what age did s/he say his/her first word?

Does your child have any known allergies (food or other)? Please list in detail below

How does your child respond to separation and transition?

What time does your child go to sleep?

Is there anything else we should know to better understand your child?

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Increase the amount by 2.5% to cover credit card fees. Please select YES to increase your payment.

Total: