Transitioning to Kindergarten
Child's Name ________________________________________________________________________________________
Basic Information
Name(s) of Person(s) completing this form: _________________________________________________________________
Date: _______________________________________________________________________________________________
School: _____________________________________________________________________________________________
Child likes to be called: _________________________________________________________________________________
Child's date of birth: ____________________________________________________________________________________
Mother's name: _______________________________________________________________________________________
Father's name: _______________________________________________________________________________________
Other adult(s) living in the home: __________________________________________________________________________
Address: ____________________________________________________________________________________________
Phone(s): ___________________________________________________________________________________________
Best time to reach us: __________________________________________________________________________________
About My Child
My child's favorite things:
favorite color _________________________________________________________________________________________
favorite food __________________________________________________________________________________________
favorite book _________________________________________________________________________________________
favorite toy ___________________________________________________________________________________________
favorite expression ____________________________________________________________________________________
other favorites: ________________________________________________________________________________________
My child is good at:
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My child likes to (check all that apply):
Listen to stories _________________
Draw and color __________________
Play alone ______________________
Play with other children ____________
Play outside ____________________
Play quiet games inside ___________
Go to a friend's house _____________
My child doesn't like to:
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I'd like you to know this about my child:
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My child learns best by:
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About My Child's Early Learning Experiences at Age 4:
If your child is not enrolled in any program, check here______
My child has been enrolled in (name of preschool or program) _____________________________ from (date) _____________
to (date) ___________________.
This is a (check one):
Child Care Center ________________________________
Family Child Care Home ___________________________
Parents as Teachers program _______________________
Other __________________________________________
For more information about this program, contact:
Name: ______________________________________________________________________________________________
Phone: ______________________________________________________________________________________________
About Our Family:
We speak the following languages in our home: ______________________________________________________________
Most of the time, I speak (write in language) ________________________________________________________ to my child.
Most of the time, my child speaks (write in language) ____________________________________________________ to me.
Some things I'd like you to know about my family (culture, activities that the family enjoys doing together, other):
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There are ____________ children in the home. Their ages are:
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The best times for me to come to the school are:
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My family would like to share the following skills or activities with our child's class or school:
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Screenings and Special Services:
My child had a hearing screening on (date) _____________ at (location) _____________.
Results:
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My child had a vision screening on (date) _____________ at (location) _____________.
Results:
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My child had other screenings: Speech: date___________location_______
Results:
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Other (please describe):
My child receives these supports and special services: If your child does not receive any special services, check here: ___
Type of Service received last year receives this year amount of time per week should receive in kindergarten Occupational Therapy (OT)
Physical Therapy (PT)
Speech and Language (S/L)
Social Worker
Other (Please describe):
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I would like you to observe my child because I am concerned about the following:
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Thank you for getting to know my child!
We want to work with you to ensure a successful kindergarten year!
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Signature Date
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Signature Date
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