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Date: __________

Dear Parents,

WCC Child Care Questionnaire

The staff at WCC Children's Center desire to offer the very best care and education for your child. In order to do this it is helpful for us to have background information on your child. Please take a moment to fill out the attached questionnaire. This information is kept confidential and is used only to enhance your childs experience at the Childrens Center. Thank you, The Children's Center staff
Please fill out ALL spaces as completely as possible:

Childs Name: Male Female Birthday:

Childs Nickname: Language spoken by the child:

Parents Name: Occupation: Parents Name: Occupation: Custody/visiting arrangements: Other children and adults living in the household: Name Age

Age: Language spoken by the parent: Age: Language spoken by the parent:

Relationship

Have there been any recent changes in the family or do you think there may be any changes during the next 3 months? (List changes of house, room bed, food, bottle, toileting or bedtime; separation, divorce, new family or step-family member; new boy/girl friend, roommates; illness of parent, family member or child; death of friend or family member, hospitalization, new baby, etc.)

In general, how does your child react to anxiety or stressful situations? (Does he/she cry, withdraw or throw tantrums?)

Revised 10/12/09

Continued on the other side

Has your child had any other childcare experience? Explain.

Does your child have any special needs? If yes, please explain. What adaptations will your child need?

Does your child use the toilet on his/her own?

Is there anything in your childs developmental history, such as, language, learning or emotional difficulties or physical characteristics, you feel we should know to help us care for your child more effectively?

What are your childs likes and dislikes?

What activities does your child enjoy best?

What skills do you want your child to learn?

Describe your childs best attribute.

In what areas does your child need support?