Kindergarten Questionnaire

Date: _____________________

Family Background:

Child’s Name: ___________________________________________________________________

Nickname: ______________________________________________________________________

Birthday: ______________________________________________________________________

Home phone number: ______________________________________________________________

Address:  ______________________________________________________________________

Business phone numbers and hours:

            Mother: __________________________________________________________________

            Father: __________________________________________________________________

Other children in family:

            Name                                                  Age                                                     Grade

            _______________________________________________________________________

            _______________________________________________________________________

            _______________________________________________________________________

            _______________________________________________________________________

Has there been a divorce, death, or illness in the family which might affect your child? __________  (If yes, circle which)

Social Experience:

1. Has your child attended nursery school? _____________  If yes, which one? _____________ _________________________________   For how long? __________________________
2. With whom does your child play? ___alone   ___with older children    ___with younger children   ___with children of the same age   ___with boys   ___with girls
3. Would you say your child is a leader or a follower? __________________________________
4. What activities does your child enjoy outdoors? ____________________________________   
5. What activities does your child enjoy indoors? _____________________________________
6. How many hours of television does your child watch per week? __________________________
7. How often is your child read to? ________________________________________________
8. What holidays do you celebrate at home? _________________________________________ _________________________________________________________________________

Development:

1. Does your child have any health problems the school should be more aware of? ________ If so, please describe: ____________________________________________________________
2. Does your child have any food allergies? ________.  If yes, please specify: ________________ _________________________________________________________________________
3. Please check what your child is capable of doing without assistance:    ___button    ___tie shoes   ___snap    ___dress themselves   ___recite birthday   ___recite address   ___recite phone # 
4. Is your child able to print his or her first name? ___________ Last name? ______________
5. Is your child able to be in a new situation without an undue amount of fear? _______________
6. Check the characteristics that apply to your child:  ___cries easily     ___has temper tantrums  ___sulks  ___has sleeping problems   ___whines  ___has eating problems    ___is easily angered  ___daydreams    ___does not like to share    ___other(please explain: ___________________)
7. What would you say are your child’s strengths? _____________________________________ _________________________________________________________________________
8. What would you say are your child’s weaknesses? ____________________________________ _________________________________________________________________________

School Adjustments:

1. Is your child able to sit and listen to a story for 10 minutes? ___________________________
2.  Does your child listen without interrupting while someone else is talking? __________________
3. Is your child able to share and take turns? ________________________________________
4. What do you expect your child to acquire through the kindergarten experience? _____________ __________________________________________________________________________
5. What else would you like me to know about your child? ________________________________ __________________________________________________________________________

                  Mother: _____________________________________________________________

                  Father: _____________________________________________________________

Please remember… You may call or write me anytime.  You are encouraged to contact me regarding anything you feel might affect your child’s education.

Thank you for your time!

Miss Cindy Credico

Ccredico@cwcboe.org