Child/Parent Information Survey
Ms. Appel’s Kindergarten Class
Child’s Name:
Birthday _________________ Age _____________ (years) ___________ (months)
1. Parents’/Guardians’ name and relationship to child:
Name Relationship
2. Has your child had preschool or play-group experience? (Name of school/years attended)
3. Does your child have any diagnoses that I should be aware of? (ex: speech therapy, physical therapy, etc.)
4. Does your child have any health problems or allergies?
5. What skills has your child acquired? (check if applicable) can say full name
knows home address can print full name
knows phone number knows birthday can identify colors can tie shoes
knows names of colors knows difference between right and left
6. What languages do you and/or you child speak?
7. What do you believe are your child’s strengths and weaknesses?
8. Does your child have any special interests? What motivates your child?
9. What might cause anxiety for your child?
10. How would you rate your child’s attitude towards school? (circle)
11. What are your expectations for kindergarten? What specific things would you like to see happen this year?
12. Will your child be attending after care? (circle)
If yes, what days of the week (circle)
Monday Tuesday Wednesday Thursday Friday
13. Who will be picking up your child up and their relationship to the child? (list all people!)
Name Relationship
14. Do you have any other questions or concerns?
This will be an exciting year! I am looking forward to getting to know you and your child.
-Ms. Appel