GROUP EXPERIENCESWHAT IS/ARE YOUR CHILD’S FAVOURITE TOY(S)/ACTIVITIES?(Required) HAS YOUR CHILD HAD PREVIOUS PLAY GROUP EXPERIENCE?(Required) Yes No IF YES, HOW DID HE/SHE ADAPT? HOW DOES YOUR CHILD BEHAVE TOWARD OTHER CHILDREN [E.G., SEEKS OTHERS OUT, FEELS SHY]:(Required) EMOTIONALHOW DOES YOUR CHILD REACT WHEN LEFT WITH UNFAMILIAR PEOPLE AND/OR IN UNFAMILIAR SITUATIONS?(Required) DOES YOUR CHILD HAVE ANY PARTICULAR FEARS? PLEASE DESCRIBE:(Required) WHAT SUGGESTIONS DO YOU HAVE THAT WOULD HELP STAFF TO MAKE YOUR CHILD’S TRANSITION INTO THIS PROGRAM EASIER?(Required) PLEASE LIST THE NAMES OF THE SIGNIFICANT PEOPLE IN YOUR CHILD’S LIFE [E.G., SIBLINGS, GRANDPARENTS, ETC.]:(Required) PLEASE DESCRIBE THE GUIDANCE AND DISCIPLINE METHODS USED AT HOME:(Required) PRIMARY LANGUAGE SPOKEN IN THE HOME:(Required) OTHER LANGUAGES:(Required) NAME OF ENGLISH SPEAKING PERSON [IF NEEDED] PHONE SIGNATUREEATING AND NUTRITIONLIST YOUR CHILD’S FAVOURITE FOOD:(Required) LIST ANY DISLIKED FOOD:(Required) PLEASE DESCRIBE ANY PARTICULAR EATING PATTERNS:(Required) ARE THERE ANY RELIGIOUS OR ETHNIC OBSERVANCES RELATED TO FOODS:(Required) SLEEPINGNAP TIME: HOW LONG TO SETTLE TIME OF WAKING:(Required) BEDTIME: HOW LONG TO SETTLE TIME OF WAKING:(Required) IS YOUR CHILD A DEEP SLEEPER, OR DOES (S)HE AWAKEN EASILY?(Required) DOES YOUR CHILD TAKE A FAVOURITE COMFORTER [E.G., BLANKET OR TOY] TO BED?(Required) Yes No IF YES, PLEASE DESCRIBE AND TELL US IF IT IS “NAMED”:(Required) WHAT IS YOUR CHILD’S MOOD UPON WAKENING?(Required) TOILETINGTOILETING IS YOUR CHILD TOILET-TRAINED?(Required) Yes No Partially PLEASE INDICATE YOUR CHILD’S FREQUENCY OR PATTERNS FOR BOWEL MOVEMENTS:(Required) DESCRIBE ASSISTANCE NEEDED FOR TOILETING:(Required) WHAT “SPECIAL” WORD DOES YOUR CHILD USE FOR:(Required) URINATION: BOWEL MOVEMENTSName of Parent/Guardian(Required) Date(Required) MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.
