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Registration Form
(This information will be kept confidential.)
Childs Name: _________________________________________________________
Birthdate: __________________________ Sex:______________________________
Address: _____________________________________________________________
_____________________________________________________________________
Home Phone: ______________________ Cell Phone: _________________________




Name and E-mail addresses: ______________________________________________
_____________________________________________________________________
Special talent, skill or hobby that you are able to share with the class:_____________
_____________________________________________________________________
Siblings Names, Birth date, School
1. ______________________________ ______________ ______________________
2. _______________________________ ______________ _____________________
3. ______________________________ ______________ ______________________
Language(s) other than English spoken in home: ______________________________

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1. Is this your childs first preschool experience? _____________________________

If not, list camps or schools previously attended: ______________________________
2. Is your child potty trained? _____________________________________________
3. What type of play does your child prefer? (Please check as many behaviors as
apply.)
ACTIVE _____________________

IMAGINATIVE PLAY ___________

ALONE _____________________

QUIET_______________________

WITH AN ADULT _____________

DRAWING ___________________

INDOOR ____________________

WITH A PEER _______________

OUTDOOR __________________

DOLLS _____________________

CRAFTS ____________________

DRESS-UP __________________

MANIPULATIVES _____________
MUSIC _____________________

OTHER: ____________________

DANCING___________________

___________________________

CONSTRUCTION _____________

___________________________

BLOCKS ____________________

___________________________

TRAINS _____________________

___________________________

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4. Which behaviors best describe your child when upset?

(Please check as many behaviors as apply.)

REGAINS COMPUSURE EASILY _________CRIES EASILY _________________

HAS TEMPER TANTRUMS ______________ BITES ________________________
HITS _________________________________ KICKS ________________________
VERBALLY LASHES OUT ______________WITHDRAWS __________________
OTHER: _____________________________________________________________
5. What situations might cause your child to become upset?
(Please check as many behaviors as apply.)

SHARING ______________________ SEPERATION ISSUES _________________

LIMIT SETTING ________________ PHYSICAL TOUCH___________________
LIGHTNING ___________________

LOUD NOISES _______________________

FOOD ISSUES __________________ TOILET _____________________________

OTHER: _____________________________________________________________
6. Does your child have any special needs or learning issues that you are aware
of?__________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

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7. Please list any food allergies your child has:________________________________

_____________________________________________________________________
_____________________________________________________________________
8. Please list any airborne allergies your child has:_____________________________
_____________________________________________________________________
9. What method of discipline is used in your home?____________________________
_____________________________________________________________________
10. What is your childs reaction to this discipline?____________________________
_____________________________________________________________________
12. Is there anything else that you would like us to know about your child that would
help us to better understand her or him?_____________________________________
_____________________________________________________________________
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To secure your childs place, send this form to the above address along with a $50.00
non-refundable registration fee ($75.00 max per family) payable to Miss Trish.
Parents/Guardians Signatures____________________________________________
Date_________________________________________________________________

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