Gan Chabad Health Form

GENERAL INFORMATION

Child's Name:*

First NameLast Name

Birth Date:*

MonthDayYear

Home Phone Number:*

Area CodePhone Number

HEALTH

Health History:

Has there ever been a history of previous communicable diseases? If yes, please explain in detail:

Allergies or Medical Conditions:

Special Diet or Medication Required:

EMERGENCY CONTACT INFORMATION

Mother's Information

Mother's Information

Name:*

PrefixFirst NameLast Name

Home Address:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Work Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone Number:*

Area CodePhone Number

Work Phone Number:*

Area CodePhone Number

Father's Information

Father's Information

Name:*

PrefixFirst NameLast Name

Home Address:*

Street Address
Street Address Line 2
City	Province
Postal	Country

Work Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone Number:*

Area CodePhone Number

Work Phone Number:*

Area CodePhone Number

Emergency Contact

Emergency Contact

Name:*

PrefixFirst NameLast Name

Address:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number:*

Area CodePhone Number

Relationship to Child:*

Child's Doctor Information

Child's Doctor Information

Name:*

PrefixFirst NameLast Name

Address:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number:*

Area CodePhone Number

If an emergency arises (G-d forbid) and none of the people specified above can be contacted, I hereby give Gan Chabad permission to take any measures deemed proper considering the circumstances.

AUTHORIZATIONS FOR PICK-UP

# 1- Full Name:*

PrefixFirst NameLast Name

Phone Number:*

Area CodePhone Number

Address:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Relationship to Child:*

#2- Full Name:

PrefixFirst NameLast Name

Phone Number:

Area CodePhone Number

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Relationship to Child:

#3- Full Name:

PrefixFirst NameLast Name

Phone Number:

Area CodePhone Number

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Relationship to Child:

#4- Full Name:

PrefixFirst NameLast Name

Phone Number:

Area CodePhone Number

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Relationship to Child:

Child will not be release to any individual not in this section unless otherwise indicated in writing by parents/guardian.

PARENT ASSESSMENT

In order to provide you and your child with the best experience possible, and to ensure that we meet his/her developmental needs and goals, please complete the following questionnaire and return with forms. This information is confidential, and will be used by the classroom teacher to enhance the curriculum planning and sensitivity to each individual child. Assessing your child’s development during the year is an on-going process, and we encourage your feedback and involvement. Please answer as many questions as you feel comfortable answering.

What sparks your child's Interest?

What kinds of activities engage your child’s focused attention?

Does your child have any special need of which we should be aware in the classroom setting?

What are your child’s special abilities and talents?

Please share the cultural background/history of your family.

Please identify the primary and secondary languages spoken in your home; how and when are they used with your child.

Is there anything in your child’s or family’s life that might affect his/her adjustment to school?

What behaviors are you finding challenging to deal with right now?

How do you deal with the above challenging behaviors?

How would you describe your most important family values?

Please define your child rearing philosophy.

Please assess your child’s developmental progress based on your own perceptions in the following areas:

Social Skills:

EmergingAverageAdvanced

Emotional Skills:

EmergingAverageAdvanced

Language Development:

EmergingAverageAdvanced

Listening Skills:

EmergingAverageAdvanced

Visual Discrimination Skills:

EmergingAverageAdvanced

Gross Motor Skills:

EmergingAverageAdvanced

Fine Motor Skills:

EmergingAverageAdvanced

Physical Development:

EmergingAverageAdvanced

As a parent, what are your expectations of your child’s growth and development while in our program?

What goals would you like us to work toward together this year?

What specifically do you enjoy and appreciate about our program, that you would like us to continue and expand?

Other comments about your child’s developmental progress you wish to share.

Are you interested in serving as a parent resource to our curriculum? Do you have special talents, skills, or cultural knowledge that you would like to share with our program?

Thank you for sharing your insights with us. It will help us to know your child better. Throughout the year, please be sure to update us on the results of observations from home –so we may better adjust the curriculum and focus.

Name of Applicant:*

PrefixFirst NameLast Name

Immunization Records*

I submitted a copy of my child's immunization recordI will submit a copy of my child's immunization record

Date of Admission

Date of Discharge

General Information

Health

Emergency Contact Information

Authorizations for Pick-Up

Parent Assessment