SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

 

 

KINDERGARTEN INFORMATION FORM

 

 

Name:

 

Nickname:

Address:

 

Birthdate:

Home Phone:

 

E-mail:

Father’s Name:

 

Mother’s Name:

Father’s Occupation:

 

Mother’s Occupation:

Father’s Work Phone:

 

Mother’s Work Phone:

 

Emergency name and phone number: (local)________________________________________

 

            Other children in family                                                                    Age

 

___________________________________                                      ________________

 

___________________________________                                      ________________

 

___________________________________                                      ________________

 

Did he/she attend nursery school?________Where?__________________________________

 

Does he/she have any vision problems?___________________________________________

 

Does he/she have a speech or hearing problem?_____________________________________

 

Does he/she have special physical needs? (corrective shoes, corrective surgery, medications, etc.)

___________________________________________________________________________

 

Methods of discipline used: ____________________________________________________

 

List special interests (toys, pets, etc.) _____________________________________________

 

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