Professional Documents
Culture Documents
Ministry of Education
Child's Name: Does your child have a nickname? Yes No If Yes, what is it?
Family
Names of brothers and sisters (include nicknames) Birth dates Does this sibling live in the same home as this child?
Relationship to child
What languages are spoken in your home? Does your child have any pets? Yes No If Yes, what are they?
Food
Describe your child's appetite:
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Yes
No
Lunch
Snack
Supper
Self-Care
Please comment about bathroom routines or training procedures: Is your child in diapers? Has training begun? Is your child completely trained? Does your child need help? Do you use any special words pertaining to toileting? Does your child need any help with dressing? Yes Yes Yes Yes Yes Yes No No No No No No If Yes, please list: If Yes, what kind of help?
Yes
No
Do you or does your child have any concerns relating to nap time?
Yes
No
Please describe:
Social/Emotional Development
Does your child spearate easily from you? Yes No Please comment:
No
Sometimes
Yes
No
Please describe:
How does your child show feelings of: Affection Fear Anger Frustration Excitement
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Does your child have a favorite toy, blanket, bottle or soother? Please identify.
Yes
No
Yes
No
Please describe:
Yes
No
Discouraged?
Provide any further information relating to your child that would be helpful in understanding and caring for your child.
Note: Personal health information may be disclosed to the Ministry of Education in the course of reviewing the facility's record keeping obligations.
Date
/
Year Month
/
Day
Parent/Guardian signature
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