Child’s Name: ________________________________

Date of Birth: ________________________

Days in care:
Name of Parents:
Mother: _____________________________ Father: _____________________________
Sibling/s: __________________________________ Pets: _____________________________

Who lives at home? _______________________________________________

Cultural Heritage: _________________________________ Religion: _________________________________

First/Home Language: __________________________

Allergies/ Relevant Medical Information:

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

What are 3 words that best describe your child

1. _____________________ 2. ______________________ 3. _____________________

What are your child interests?

_____________________________________________________________________
_____________________________________________________________________
Goals I have for my child

Any extra notes that you would like me to be aware about?

_______________________________________________________________________________
_______________________________________________________________________________


Thank you for taking the time to fill out this form & assisting me with my studies J