CHILD QUESTIONNAIRE

Fill the form Child Questionnaire

Date Completed

Child's Name*

DOB*

Age*

HEALTH
Please include in your answers all that applies

Does your child have any existing injuries?*

Has your child had the chicken pox or measles?*

Does your child use glasses, a hearing aid, or other physical assistance devices?*

Does your child have any allergies to food, medication, environment, or other (indicate whether an Epipen is required)?*

Please tell us if any other health related information would impact your child's time at Haymarket Children's Academy?*

SOCIAL

Describe your child's temperament

What does your child like to do?

Does your child have special fears?

How does your child respond to a stressful situation?

What seems to help your child feel better?

What method of discipline do you use at home?

Has your child been in previous child care?

FAMILY

Who lives with the child? Mother

Father

Brother and/or Sister

Other

Child's Grandparents (the names your child uses):

AGE RELATED

Nap Schedule

Feeding Schedule

Breast Fed?

Formula and type?

PRESCHOOLERS

Is your child potty trained for urine?

Bowels?

How does your child communicate that he/she needs to use the toilet?

Is there any information about your child's eating habits we should know?

SCHOOL AGE

What school does your child attend?

Grade?

Favorite Subjects?

Do you want your child to begin their homework with us or at home?

Does your child have an Individualized Education Plan? If so, please provide

What are your child's hobbies, sports, and/or special interests?

Is there any information about your child's eating habits we should know?

ALL CHILDREN

Is there anything else that we should know to help us provide the very best care for your child?*

PROOF OF IDENTITY
Virginia law requires proof of a child's identity and age upon enrollment unless the child is currently enrolled in public school and Haymarket Children's Academy assumes responsibility for the child directly from school. This proof includes a birth certificate, passport, or public school certification. Please bring a document proving your child's identity to parent orientation.

Administrator*

Date*

CHILD QUESTIONNAIRE

Fill the form Child Questionnaire

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