Student Info Sheet 2022-2023

Student Name *

Date of Birth * +

Please call my child *

Was your child premature? *

Parent's/Guardian's Names *

Occupations *

Sibling's Names and Ages *

Does child live with one or both parents? Explain *

Home Address *

Home Phone Number *

Email Address for Teacher/Office Communication *

Other Phone Numbers (names and cell #'s / work #'s) *

Other Emergency Contact's Names and Phone Numbers *

Names and Phone Numbers of Persons Authorized to pick up your child *

Codeword (to be used in lieu of ID) *

Are you a member of New Hope Church? *

Is your child receiving any services for speech, hearing, or occupational needs? If yes, please describe *

What language do you speak at home? *

Food or other allergies *

Does your child have fears? If so, please explain. *

Are there any holidays in which you do not participate? *

What are your child's favorite activities? *

What hopes or expectations do you have for your child from our program? *

Any other information that you feel would be beneficial for us to know? *