Parent Information
Parent 1
Full Name
Phone Number
Home Address
Email
Parent 2
Full Name
Phone Number
Home Address
Email
Emergency Contacts
Emergency Contact 1
Name
Phone Number
Relationship to Child
Emergency Contact 2
Name
Phone Number
Relationship to Child
Child Information
Child 1
Full Name
Date of Birth
1. Please list all allergies we should be aware of. This includes dietary preferences/restrictions.
2. Are there any medical/health concerns?
3. What are some of your child's favourite activities/things to do?
4. What are some of your child's least favourite activities/things to do?
5. What are your child's strengths?
6. Name an area(s) of development that can be improved (if any)
7. What is your child's temperament?
8. What is your child's current routine? E.g. Wake up time, bed time, nap time, after school routine, etc.
9. Are there specific goals you are working towards with your child? E.g. toilet training
10. Any other comments/notes that we should be made aware of?
Child 2
Full Name
Date of Birth
1. Please list all allergies we should be aware of. This includes dietary preferences/restrictions.
2. Are there any medical/health concerns?
3. What are some of your child's favourite activities/things to do?
4. What are some of your child's least favourite activities/things to do?
5. What are your child's strengths?
6. Name an area(s) of development that can be improved (if any)
7. What is your child's temperament?
8. What is your child's current routine? E.g. Wake up time, bed time, nap time, after school routine, etc.
9. Are there specific goals you are working towards with your child? E.g. toilet training
10. Any other comments/notes that we should be made aware of?
Family Information
1. What are your family's core values?
2. What are activities that you like to do as a family?
3. What is your philosophy around behaviour guidance? Are there particular tools that you use to help guide and facilitate behaviour?
4. What are your limits on TV/Screen time?
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