Kersey Early Learning Center @ Platte Valley Early Learning Center “Sparking Curiosity for a Lifetime of Learning” P.O. Box 566 Kersey, Colorado 80644 Phone: 970-336-8760

Admission Record Date of Application: ________________________ Start Date: ___________________________

CHILD INFORMATION: Child’s Name: __________________________________ Date of Birth: ___________________ Current Age: _________________ Sex: M_______ F_______ Address: ______________________________City: __________________ Zip: ____________ Language spoken by child: ________________ If child is adopted: Age at adoption: ______Does child know he/she is adopted? ______Remarks: ______________ _____________________________________________________________________________ Child’s Ethnic Group __American Indian/Alaskan Native __Asian or Pacific Islander __African American-Not of Hispanic Origin __Hispanic __White-Not of Hispanic Origin

ALL ABOUT YOUR CHILD What opportunities has your child had to play with other children his/her age?

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What child care experiences has your child had outside the home?

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Explain how your child interacts with other children.

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Explain how your child interacts with other adults.

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Explain how your child responds to redirection.

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Does your child have any allergies? If yes, please list and describe reaction and steps you would like us to follow. _____________________________________________________________________________________ _____________________________________________________________________________________

______________________________________________________________________________ Does your child have any special needs? (i.e. seizures, asthma, diabetes, heart disease, speech difficulties, etc.) If so, please describe and give instructions for care. _____________________________________________________________________________________ _____________________________________________________________________________________

______________________________________________________________________________ List your child’s likes, dislikes or any fears your child may have. _____________________________________________________________________________________ _____________________________________________________________________________________

______________________________________________________________________________ Explain concerns, if any, about your child attending preschool.

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Do you have any specific concerns or questions about your child?

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please list any goals you would like to see your child achieve while attending preschool. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

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PARENT/LEGAL GUARDIAN INFORMATION: Father/Guardian Name: _________________________________________ Age: __________ Home Address: ______________________________City: _________State: _______Zip ______ Place of Employment/Occupation: _________________________________________________ Address of Employment: ___________________________City: _______State: ____Zip_______ Phone Numbers: Home ____________________ Work __________________ Ext. __________ Cell _______________ Email ______________________________________ Language Spoken by Father: ____________________________________ Education: (Please check one) __Less than high school __High school diploma/GED __Some College __Completed an Associates or Technical Degree __Completed a 4 year Bachelor’s Degree __Completed a Graduate degree

Ethnic Group: (Please check one) __American Indian/Alaskan Native __Asian or Pacific Islander __African American-Not of Hispanic Origin __Hispanic __White-Not of Hispanic Origin

Mother/Guardian Name: __________________________________________ Age: _________ Home Address: ______________________________City: _________State: _______Zip ______ Place of Employment/Occupation: _________________________________________________ Address of Employment: ___________________________City: _______State: ____Zip_______ Phone Numbers: Home ____________________ Work __________________ Ext. __________ Cell _________________Email _____________________________________ Language Spoken by Mother: ____________________________________ Education: (Please check one) __Less than high school __High school diploma/GED __Some College __Completed an Associates or Technical Degree __Completed a 4 year Bachelor’s Degree __Completed a Graduate degree

Ethnic Group: (Please check one) __American Indian/Al askan Native __Asian or Pacific Islander __African America n-Not of Hispanic Origin __Hispanic __White-Not of Hispanic Origin

Parent Marital Status ( )Married ( )Single ( )Divorced ( )Widowed If divorced who has custody and what are the visiting arrangements? ______________________________________________________________________________ ______________________________________________________________________________

FAMILY INFORMATION: Please list siblings of the child: (include name, age and current grade in school) ______________________________________________________________________________ ______________________________________________________________________________ Please list all people living in the home: (include name, relation to child and age) ______________________________________________________________________________ ______________________________________________________________________________ Has your child ever been in or are they currently in foster care? If so, please list date(s) and case worker from Department of Social Services. ______________________________________________________________________________ ______________________________________________________________________________ Please check agencies that may be involved with your family. (Check all that apply) __Public Health __WIC __Social Services __Child Care Assistance Program (CCAP) __Family Assistance Programs (TANF, SSI, Food Stamps) __Free and/or Reduced School Lunch Program (Does an older sibling qualify?) Have there been any recent changes in your lives? (Examples: jobs, financial, relationships, death, divorce, moves, adoptions, etc…) ______________________________________________________________________________ ______________________________________________________________________________ How long have you been at your current address and how many times have you moved in the past 5 years? ______________________________________________________________________________ ______________________________________________________________________________ Is there a family history of learning problems? If so, please explain. ______________________________________________________________________________ ______________________________________________________________________________ Does anyone in the family have any chronic health problems or serious illnesses? (Examples: allergies, asthma, diabetes, cancer, heart disease etc…) ______________________________________________________________________________ ______________________________________________________________________________ Does anyone in the home have a disability? ______________________________________________________________________________ ______________________________________________________________________________ Are there any family situations that affect your child? (Examples: divorce, behavior of siblings, alcoholism, etc…) ______________________________________________________________________________ ______________________________________________________________________________

Child Health History

Child’s Name: ____________________________________Date of Birth:__________________ Parent’s Name: _________________________________________________________________ Address: ________________________________________ Phone Number: ________________ Doctor’s Name: __________________________________ Last Physical: __________________ Dentist’s Name: __________________________________ Last Exam: ____________________ Area of Concern:

Please check any areas that you have concerns about your child’s development. ___Learning ___ Gross Motor Skills (running, jumping etc) ___ Hearing ____Fine Motor Skills (writing, pencil grasp) ___ Social Skills (behavior, friends) ____Vision ___ Speech Skills (articulation, intelligibility) Other comments:

______________________________________________________________________________ ______________________________________________________________________________ Pregnancy Information:

Age of Mother at birth: ___________________________ Age of Father at birth: ____________ Birth order of child: ____ Mother’s Weight gain: ____ When did you start doctor care? _______ Please check area of concern during pregnancy: ___ Swelling of hand/face ___ Bleeding ___ Anemia ___ High Blood Pressure ___ Kidney/bladder problems ___ Diabetes ___Seizures ___ Accidents/Injuries ___ Hospitalized before birth ___Other Illnesses: __________________________________________ Other concerns: _________________________________________________________________

Did you drink alcohol during pregnancy? ___ Yes ___ No If yes, how much? _____________ Did you smoke during pregnancy? ___ Yes ___ No If yes, how much? __________________ Did you use prescription drugs during pregnancy? ___ Yes ___ No If yes, please list. ______________________________________________________________________________ Did you use street drugs? ___ Yes ___ No If yes, please list. ______________________________________________________________________________ Were you under stress during pregnancy? ___ Yes ___ No If yes, please describe. ______________________________________________________________________________ Was this a planned pregnancy? ___ Yes ___ No Birth/Delivery History:

Was the baby born “on time”, late or early? __________________________________________ If baby was born early or late, how many days or weeks? _______________________________ Please describe any problems with labor. ____________________________________________ Were medications or anesthesia used? _______________________________________________ Was your delivery vaginal or c-section? _____________________________________________ Where was the baby born? ________________________________________________________ Did the baby cry immediately? ____________________________________________________ How much did the baby weigh? __________ Check if your baby had: ___Jaundice ___Seizures ___Breathing Problems ___Cord Around Neck ___Poor sucking/swallowing Other: ______________________________________________

Developmental History: At what age did your child: Crawl: ____ Finish toilet training Bowel: ____ Bladder: ____ Walk alone: ____ Begin saying words: ____ Begin sentences: ____ Is speech clear and understandable? ___ Yes ___ No Which hand does your child use more or is it equal? ___________________________________ Any concerns about your child’s growth? ____________________________________________ ______________________________________________________________________________ Physical Condition: Check if child has had any of the following: ___ Colds/Infections ___ High Fevers ___ Constipation/Diarrhea ___ Diabetes ___ Ear Infections-tubes ___ HIV/AIDS ___ Speech Problems ___ Contagious Diseases ___ Burns ___ Sleep Disorders ___ Head Injuries/Concussion

___ Infectious Hepatitis ___ Pneumonia/Bronchitis ___ Asthma/Chronic Cough ___ Tonsillitis/Strep Throat ___ Bladder/Kidney Problems ___ Visual Problems/Glasses ___ Dental Problems ___ Physical/Sexual abuse ___ Failure to Thrive ___ Seizures ___ Bedwetting/Daytime wetting

___ Fractures ___ Meningitis ___ Tuberculosis ___ Chickenpox ___ Hearing Problems ___ Eating Disorders ___ Heart Problems ___ Indigestion ___ Poor Weight Gain ___ Bowel Accidents ___ Allergies Food Allergies: ________________ Medication: ___________________ Reaction to allergy: ____________________________________________________________________ Other comments: ______________________________________________________________________

Has your child: Been Hospitalized? ___ Yes ___ No Comment: __________________________________________________________________ Had any Operations? ___ Yes ___ No Comment: __________________________________________________________________ Been seen in Emergency Room: ___ Yes ___ No Comment: __________________________________________________________________ Taken Medication? ___ Yes ___ No Comment: __________________________________________________________________ Are immunizations current? ___ Yes ___ No Comment: __________________________________________________________________ Behavior: Do you have concerns about your child’s behavior? ___ Yes ___ No Check any concerns about the following behaviors: ___ Bad dreams ___ Nail Biting ___ Nervousness ___ Restlessness ___ Thumb Sucking ___ Irritable, Easily Upset ___ Breath Holding ___ Jealously ___ Fears ___ Frequent Complaints ___ Selfish ___ Bad Temper ___ Overactive ___ Glum, Sulky, Moody ___ Stubborn ___ Disobedient ___ Discipline Problems ___ Destroys things purposely ___ Overly Sensitive ___ Has difficulty separating from parents ___ Wants too much attention ___ Other: _________________________________________________

Permission for Health Advisory: The Platte Valley School District Health Office develops a Student Health Advisory List each school year. This list is used to inform teachers, and other necessary staff about your student’s health condition, so as a team we can provide the best care for your student while at school. This information is considered CONFIDENTIAL and is shared only on a “need to know” basis. I give my permission to inform teachers and necessary staff about my students identified health concerns. This permission shall be continuously in effect unless terminated by written notice from myself to the school health office at school in which my student is enrolled. My students identified health condition is: ___________________________________________ Signature of Parent/Guardian: ______________________________________Date: __________ Printed Name: ______________________________ Relationship to Student: _______________