ECC Child and Family Information Form - Temple Beth El of Northern Westchester

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We designed this form to learn more about you, your child and your family. Please answer the questions as thoughtfully as possible. The information you provide will not only help us get to know you and your child, but it will also help us to create a nurturing environment.

The questions we ask are not meant to make you feel uncomfortable in any way. You may leave blank spaces if you do not wish to answer a question. There is no right or wrong answer and all information you share will be kept confidential (it is shared with classroom teachers and school directors). Our hope is that by getting to know your family, we may join you in the care of your child.

Thank you for taking the time to complete this form.

Child's Name

Date of Birth

Preferred Name

Tell us 3 things we should know about your child.

What languages do you speak at home?

What are some of your child's favorite things to do?

Does your child have any fears that we should be aware of? Do they have any particular sensitivities (for example, loud noises-fire alarms, different textures-food, cold/hot weather)?

Have there been any major changes in your family within the past year (new home, new job, divorce, illness, death, birth, etc.)? How has your child responded to these changes?

Does your child nap?

How does your child show that they are upset? Please tell us how you soothe or comfort your child when they are hurt, upset or need special attention?

Are there areas that are challenging for your child?

Is your child in diapers or are they toilet trained or in the process of becoming toilet trained?

If recently toilet trained, are there any issues we need to be aware of?

* Does your child have any allergies (food or other)? Please list below.

* Does your child require an EpiPen or other emergency medication? (please note if yes, we will send you additional paperwork)

Tell us about your child's sleeping habits.

Does your child receive services for special needs (occupational therapy, speech therapy, physical therapy, SEIT services)?

If yes to services, please explain.

Does your child have any special needs/developmental concerns (diagnosed or suspected)?

Has your child attended any other school or daycare? If so, where?

Which elementary school will your child attend?

What are some goals you have for your child for the upcoming school year?

What do you think your child needs from a teacher?

Are there any other caregivers in your child's life? (grandparents, nannies, babysitters) If so, please list. Will they be dropping off/picking up your child?

How does your child respond to transitions?

How does your child respond to separation?

For children entering the 2's and Temple Tots, please answer the following questions:

Has your child stayed with a babysitter or grownup that does not live in your home?

YesNo

If you left your child in the care of another adult, is your child nervous, upset or sad when separating from you?

Not at allA littleSome-whatVery

Is your child able to calm down within 20 minutes?

YesNo

Please describe what works in soothing, calming and/or distracting your child during separation:

What, if any, are your concerns about separation this fall?

Your First Name

Your Last Name

Your Email Address

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914.238.3928 temple@bethelnw.org

220 SOUTH BEDFORD RD, CHAPPAQUA, NY 10514

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