For Office Use Only
The
University
of Akron
R
E
T
T 210
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E 2 -8
EN R
C FO ILD PM 330-97
H O Ohio
C L on,
E Akr
V
E ir Hill
D 08 F
_____ UA Student
_____ Days Attending
_____ UA Faculty/Staff
_____ Flex-Time
_____ Community
_____ Full Day
_____ Other
_____ Child’s Name
___________________ Preadmission Interview Date & Time
1
Toddler Student Application
Mail completed application to
The University of Akron
Center for Child Development
108 Fir Hill
Akron, OH 44325-8210
For More Information Contact:
The Center at:
Phone: 330-972-8210
Email: [email protected]
Website: www.uakron.edu/colleges/educ/ccd/index.php
Toddler Program
1.A.02, 7.A.02
Child Profile
Child’s Name ________________________________
Gender _____ Male _____Female
Date of Birth ____________
Age: __________(years/months)
Mother’s Name ______________________________________
Home Address ________________________________________________________________
City______________________________________ State ___________ Zip Code __________
Home Phone __________________________ Cell Phone _____________________________
Business Phone ___________________________
Email Address ________________________________________________________________
Father’s Name ______________________________________Home Phone ______________
Home Address ________________________________________________________________
City______________________________________ State ___________ Zip Code __________
Home Phone _____________________________Cell Phone ___________________________
Business Phone ___________________________
Email Address ________________________________________________________________
Family Category: _____ Faculty _____ Staff _____ Student _____ Community
I am interested in: _____ All Year _____ Fall & Spring Academic Semesters only
Need Childcare Assistance:
Yes _______________
No ________________
If Yes: Full time (25 hours or more) ____________ Part time (less than 25 hours) ___________
1
Toddler Program
1.A.02, 7.A.02
Please indicate the times you would like your child to attend:
Day
7:30-
8:00-
9:00-
10:00-
11:00-
12:00-
1:00-
2:00-
3:00-
4:00-
5:00-
8:00
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
5:00
6:00
Monday
Tuesday
Wednesday
Thursday
Friday
2
Toddler Program
1.A.02, 7.A.02
DEVELOPMENTAL BACKGROUND
Physical Development & Health
Age began: sitting __________ crawling __________
walking __________ talking __________
Any difficulties with coordination? Explain. _________________________________________________
Serious illnesses and/or hospitalizations ___________________________________________________
Any physical conditions or disabilities? Explain. ______________________________________________
Is your child currently taking a daily medication? Please explain. ________________________________
EATING HABITS
Does your child have any special eating habits, difficulties and/or allergies? _______________________
____________________________________________________________________________________
Favorite foods _________________________
Foods your child refuses _________________________
TOILETING
Does your child wear diapers? _________ daytime __________ nighttime _________________
Does your child have special words or expressions to indicate bathroom needs? If yes, please explain.
____________________________________________________________________________________
____________________________________________________________________________________
If your child is toilet trained, does he/she ever have accidents? Yes ____ No ____
If so, how often? __________ daily _____
weekly _____
SLEEPING HABITS
How long does your child usually nap during the day? _________________________________________
When does your child wake-up in the morning? ________________ go to bed at night? ______________
Does your child have any special bedtime routines or needs? (stuffed animals, music, blanket, etc.)
Explain.____________________________________________________________________________
____________________________________________________________________________________
Does your child wake-up during the night or naptime and are there any other sleeping issues you would
want your child’s teacher to know? If yes, please explain. ______________________________________
____________________________________________________________________________________
Language & Cognitive Development
Has your child ever experienced any difficulties with speech or hearing? Explain. ___________________
____________________________________________________________________________________
3
Toddler Program
1.A.02, 7.A.02
Is your child bilingual? Yes____ No____
If yes, what language is spoken most at home? ___________________________
In order to help improve communication between home and school, please let us know if you will need a
translator or materials translated for you? __________________________________________________
Do you have information that you would like for us to know regarding your child’s language/ cognitive
skills? ______________________________________________________________________________
Approximately, how many hours does your child watch television? Daily? _____ Weekly? _____
PLAY BEHAVIORS
What are your child’s favorite activities or play items? _________________________________________
(dress-up, sand & water, puzzles, books, music, coloring, painting, etc.)
Does your child engage in solitary play? (solitary play is when a child plays alone with toys or
activities)____________________________________________________________________________
What kinds of play activities do you and your child like to do together? ____________________________
What things does your child show a genuine curiosity about? ___________________________________
Social & Emotional Development
Is this your child’s first formal school experience? ____________________________________________
If not, please provide us information about the previous school or activities attended.
Name of school _________________________ How long attended? _____________________
Provide a brief description of your child’s experience __________________________________________
How does your child respond to new people and places? ______________________________________
Does your child have any fears? (the dark, loud noises, children etc. ) ____________________________
What approaches do you use to help your child adapt or become comfortable to new environments or
cope with transitions?
____________________________________________________________________________________
____________________________________________________________________________________
How does your child respond to frustrations? ________________________________________________
Does your child have any special friends, playmates, or family pets? What are their names?
____________________________________________________________________________________
SELF-HELP SKILLS: Please provide us information about your child’s self-help skills. Check the following
self-help skills your child is able to do independently.
_____
_____
_____
_____
_____
Put on shoes
Pull up pants and/or Pull-ups
Put on coat
Wash his/her hands with soap & water
Use a napkin to wipe his/her mouth
4
Toddler Program
1.A.02, 7.A.02
_____
_____
_____
_____
Uses a fork or spoon when eating;
Drink from a cup
Still uses a pacifier at home
Can fall asleep by him/herself
Do you still spoon feed? __________
FAMILY RELATIONSHIPS & PARENT INFORMATION
What hours will your child be attending on a regular basis? _____________________________________
____________________________________________________________________________________
What goals do you have for your child in this program? ________________________________________
____________________________________________________________________________________
What religion (if any) do you practice at home? _____________________________
Do you have any special cultural or religion practices that you would like to share with us?
___________________________________________________________________________________
___________________________________________________________________________________
What is your child’s race/ethnic origin? ____________________________________________________
Please provide the name(s) and relationship of immediate family members residing in the home: _______
____________________________________________________________________________________
List the name and age of any siblings:_____________________________________________________
Does your child have any imaginary playmates? _________ If so, what are their names? _____________
What strategies do you use to discipline your child? __________________________________________
____________________________________________________________________________________
Is there anything else about your child that you would like to share with us? _______________________
____________________________________________________________________________________
Any other comments?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Thank you for your help and cooperation in completing this form. Your child’s profile information will be
valuable in helping us create a program to meet your child’s and family’s needs.
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