GENERAL APPLICATION  School Year _______________________

Child’s Last Name:                                                     First Name:                                         M.I.               

Nickname (if any)                                                           Birth Date:                                           

Guardian/Mother’s Last Name:                                                      First Name:                                       

Mother’s Address:                                                                                           

Home Phone:                              Business Phone:                                    Cell Phone:                            

Occupation:                                            Business Address:                                                                  

Guardian/Father’s Last Name:                                                       First Name:                                       

Father’s Address:                                                                                            

Home Phone:                              Business Phone:                                    Cell Phone:                            

Occupation:                                            Business Address:                                                                  

If either parent is active duty military, please answer questions below:

Branch of Service                                   Duty Station                             Rank                                     

Commanding Officer:                                          Phone:                                   

Sign: ______________________________ Date: _________________

 DEVELOPMENTAL HISTORY

PERSONAL HISTORY

Age began talking:                     Speaks in words?  YES  NO  Uses sentences?  YES  NO

Any difficulties speaking?  YES  NO  Language(s) spoken by child:                                          

Is your child a good climber?  YES  NO  Does he/she fall easily?  YES  NO

EATING

Is the child usually hungry at mealtime?  YES  NO  Between meals?  YES  NO

Eating problems (if any):                                           Food allergies (if any):                                                    

TOILET HABITS

What word is used for urination?                          What word is used for bowel movement?                            

Does your child need to go more frequently than usual for his/her age?  YES  NO

Is he/she frightened of the bathroom?  YES  NO  Does your child need assistance using the toilet?  YES  NO

Does your child have accidents, and how does he/she react to them?                                                               

SLEEPING

What time does your child go to bed?                 What time does he/she awaken?                                            

Is he/she ready to go to sleep at the appointed time?  What does the child take to bed?                                    

Child’s mood upon awakening:                                                                                                                        

Does he/she nap?  YES  NO  If yes, from when to when?  From:                               to:                                  

SOCIAL RELATIONSHIPS

Does your child have any experiences playing with other children?  YES  NO

By nature, is the child friendly?  Aggressive?  Shy:  Withdrawn?                                                         

Please explain:                                                                                                                                                 

Does your child get along with brother(s)?  Sister(s)?  Other adults?                                                                 

Does your child know any children at the Ewa Plains Enrichment Programs, LLC?  YES  NO

Do you feel that your child will adjust easily?  YES  NO

Does he/she demand a lot of adult attention?  YES  NO

What makes your child angry or upset?                                                                                                           

How does your child show his/her feelings?                                                                                                     

What do you find is the best way to handle your child?                                                                                     

Who does most of the disciplining?                                        Favorite activities & toys:                                    

What is your child frightened by (darkness, storms, loud noises, etc.)?                                                              

Does the child like:   to be read to?          To listen to music?              Outdoor play?           Water play?           

COMMENTS:                                                                                                                         

SIGNATURE OF PARENT OR GUARDIAN                                                                              DATE