PARENT INTERVIEW

Date deposit paid ______________________________Amount of deposit ________________________

Session enrolled ______________________________Date Child Will Start _______________________

Child’s Name ________________________________________________________________________
                            (First)                                 (Middle)                                                 (Last)

Name Child will use at The Ark Preschool _________________________________________________

Parent’s Name _______________________________________________________________________

Home Address ______________________________ Zip _________Tel. ________________________

Mother’s Work # ____________________________Father’s Work # ___________________________

Child’s Date of Birth __________________________________________________________________

Were there any special circumstances surrounding your child’s birth such as premature birth, early trauma, illness,             adoption, prolonged hospitalization, etc.? If yes, describe fully: _____________________

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Child’s age when first walked _______________________________. Child’s age when completely toilet

trained? _______________________________ What is the word your child uses for going to the

bathroom? _______________________________ What time does your child go to bed at night?

____________________________________ What time does he/she get up? ______________________

Does your child have any allergies or sun sensitivities? If yes, describe fully: _______________________

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Does your child now have, or has he/she ever had any special problems with speech, vision, hearing,

and/or health? Describe: ________________________________________________________________

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Has your child ever been hospitalized? ______________________ If yes, describe, put dates and

reasons: ____________________________________________________________________________

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Are you presently married to the child’s natural parent? _______________________________________

Length of marriage to child’s natural parent? ________________________________________________

How old was child when first separated? ___________________ When divorced? __________________

Does child see natural parent? ___________________________ Frequency __________________ Name

all the persons living in the child’s home, and describe how related to the child and how each gets along

with the child: ________________________________________________________________________

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List pets and their names: _______________________________________________________________

Length of time child has lived in present home: ______________________________________________

List any special fears your child has: ______________________________________________________

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Does your child have any special attachments such as, a blanket, thumb sucking, a toy? ______________

Describe: ___________________________________________________________________________

Does your child have any other children to play with at home or in your neighborhood? ______________

How does your child relate to them? ______________________________________________________

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How old was your child when you first went to work or left them in someone else’s care? ____________

List all the types of schools, daycare centers, babysitters, etc., that your child has had attendance in.

List by age and how long stayed: _________________________________________________________

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What is your child’s usual reaction to exposure to a new situation? ______________________________

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How do you feel this child will react to this Preschool initially? _________________________________

Describe your child’s favorite learning and playing activities at home: ____________________________

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Does your child watch TV? ________________Approximate number of hours _____________________

Types of programs which are their favorites: ________________________________________________

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Does your child:
                                                            YES         NO
…..choose own clothes to wear?     __________ __________
…..dress own self?                          __________ __________
…..go to bathroom alone?               __________ __________
…..sleep alone?                              __________ __________
…..have home responsibilities?        __________ __________
…..have any eating problems?         __________ __________

Do you have a hard time disciplining your child? _____________________Describe the discipline

procedures used by mother _____________________________________________________________

By the father _________________________________________________________________________

What is most effective and why? _________________________________________________________

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Describe any special concerns about your child: _____________________________________________

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What are you most interested in seeing the Preschool develop in your child? _______________________

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