Form Instructions:

Please print, complete and sign this form and mail it to NLF. Mail completed forms to the following address:

Nihonmachi Little Friends
Attn: Enrollment
2031 Bush Street
San Francisco, CA 94115

Child's Last Name:
Child's First Name:
Date of Birth:
Type of Birth (please circle):    Normal?    Premature?   Complications?
Age child began sitting?
Age child began crawling?
Age child began walking?
Is the child a good climber?
Does s/he fall easily?
Age began talking?
Does child talk in words?
Does child talk in sentences?
Does your child have any difficulty speaking?
other languages?
Special words to describe his/her needs:
Health
What arrangements can you make for your child's care during illness?
What communicable diseases has your child had:
chickenpox?
other?
Any serious illnesses or hospitalizations?
Any physical limitations?
Any known allergies(asthma, foods, insect bites)?
Any known allergies to topical antiseptics?
Special instructions if child becomes ill?
Any medications given regularly
Eating
Is child usually hungry at meal time?
Is child usually hungry between meals?
What are his/her favorite foods?
Does child have any eating problems?
Any food allergies?
Does child eat with (circle yes or no):
spoon?				yes     no
fork?				yes     no
hands?				yes     no
Toileting Habits
Can the child be relied upon to indicate his/her bathroom wishes?
What word is used for urination?
What word is used for bowel movement?
Does s/he need to go more frequently than usual for his/her age?
Is s/he frightened of the bathroom?
Does s/he have accidents?
If yes, how does s/he react to them?
Does child need help with toileting?
Was child easy or difficult to train?
Does s/he wet the bed at night?
If yes, how often?
Sleeping
At what time does the child go to bed?
At what time does the child awaken?
At what time is the child ready for sleep?
Does s/he have own bedroom?
Does s/he have own bed?
Does s/he sleeps alone ?
What does s/he take to bed with him/her?
What is he/her mood upon awakening?
Does s/he take naps?
If so, from when to when?
Social Relationships
Has s/he had experiences in playing with other children?
By nature is s/he friendly?   aggressive?   shy?   withdrawn?
How does s/he get along with other adults??
With what age does s/he prefer to play?
Does s/he know any children at NLF?
Do you feel that s/he will adjust easily to school?
Does s/he enjoy being alone?
How does s/he relate to strangers?
Does s/he/he demand a lot of adult attention?
What makes him/her mad or upset?
How does s/he show her/his feelings?
What do you find is the best way to handle him/her?
Who does most of the disciplining?
Is s/he frightened by any of the following:
animals?
rough children?
the dark?
loud noises ?
storms?
other?
Favorite toys and activities at home?
Does s/he like to be read to?
Listen to music?
Does s/he prefer to play outdoors?
Can s/he ride a tricycle?
Has s/he had experience with any of the following:
clay?
scissors?
blocks?
easel painting ?
water play?
finger painting ?
Family Information
Please circle one:				married		single	separated	divorced
If single, separated, or divorced, who does the child spend the majority of the time with (circle one)?				mother		father
How often does child see other parent?
If divorced, who has custody of the child?
Mother's occupation ?
Fathers Occupation ?
Does child have any siblings?
If yes, name and age
Comments
Please use a separate piece of paper if not enough space here
In what particular way can we help your child this year?:
Describe your child briefly (personal appearance, abilities, personality, etc. :

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