NORTHMINSTER COMMUNITY PRESCHOOL
1660 Kessler Boulevard, East Drive
Indianapolis, Indiana 46220
(317) 251-9489
[email protected]
www.northminsterpreschool.org
Fall, 2016
Class __________
FAMILY INFORMATION FORM
Child’s Name______________________________________________________________________
Last
First
Middle
Commonly Goes By
(Name for tote bag)
Birth date ____________________________________
Father’s Name ____________________________ Mother’s Name _____________________________
Home Address ___________________________________________________Zip Code ____________
Home Phone Number __________________________ Cell Phone Numbers ______________________
Email address ________________________________________________________________________
Marital Status of Parents: Married ____
Separated ____
Divorced ____
Widowed ____
If divorced, please describe custody and visitation agreement for the child. _________________________
_____________________________________________________________________________________
Other family members who live at home:
Name
Age
1. ______________________________
______
_________________________________________
2. ______________________________
______
_________________________________________
3. ______________________________
______
_________________________________________
4. ______________________________
______
_________________________________________
Relationship to Child
Describe your child’s opportunities to play with other children outside the family. ___________________
_____________________________________________________________________________________
Give names and types of family pets._______________________________________________________
PLEASE TURN THIS PAGE OVER AND COMPLETE THE OTHER SIDE.
Have there been births, deaths, adoptions, or other changes in the family structure which have affected your
child? If so, describe briefly what happened, the effect on your child, and how you explained this event.
__________________________________________________________________________________
Has your child had any previous school experience? If yes, please explain. _____________________
__________________________________________________________________________________
Do you currently have a church home?___________________________________________________
Where will your child attend kindergarten? _______________________________________________
What are your child’s favorite play activities? _____________________________________________
__________________________________________________________________________________
What fears does you child have? ________________________________________________________
How are these fears expressed? _________________________________________________________
What do you and your child enjoy doing together? __________________________________________
___________________________________________________________________________________
What trips, vacations, or other family experiences are remembered with the most pleasure? _________
__________________________________________________________________________________
What special happening is your child apt to tell us about? ___________________________________
__________________________________________________________________________________
How much television does your child watch each day? ________ What are his/her favorite programs?
__________________________________________________________________________________
Does you child usually use his/her right or left hand? _______________________________________
Please include any other information that will help us have a better understanding of your child’s interests and
experiences. ____________________________________________________________________
__________________________________________________________________________________
Do members of your family have a talent or special interest that they would be willing to share with the class
sometime during the school year? ___________________________________________________________