Parent Questionnaire – K5 Parent Questionnaire – K5 Parent Questionnaire – K5 Step 1 of 6 16% Child Name* First Middle Last Suffix Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current Age*Applying for GradePK3PK4Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradePerson(s) Completing the Questionnaire* Email* Thank you for completing this questionnaire about your child. As part of the enrollment process, this will help us to get to know your child. We know that children develop in individual ways so please help us to know what your child is able to do now so that we can predict how they will adjust to being in school. (Please note that we will be using “they” and “their” as a singular or plural pronoun.) I. Play and Social DevelopmentTell us about your child's relationships with you and other family members.*Give some examples of the kinds of things that your child can do independently.Give an example of what your child says or does when they are asking for something they want (like juice of milk).* Points or uses gestures 1-3 Words Full Sentence Please provide an example* Tell us about your child getting dressed in the morning.What can they do by themself?*What do they need help with?*Which of the daily tasks can your child do independently, without any adult help?*Mark all that apply. Going to the bathroom Eating Picking up toys Putting on coat Putting on shoes Opening snack containers Please provide further explanation for items you did not markTell us about your child when they are playing.What does your child like to play?*Give an example of what your child might talk about when they are playing.*How does your child play when with other children their age?* They tend to play side-by-side but not sharing toys or ideas yet They share toys and talks about ideas for play II. Physical Development Before answering these questions, you might want to do one of the following: Go on a walk. Pick-up toys and place in a basket Play outside with a ball – throwing and kicking a ball around. This will help you to have a better idea about your child’s traveling skills.Walk with good balance* Has not started yet Still developing Well developed Run with good balance* Has not started yet Still developing Well developed Can avoid obstacles when run/walk* Has not started yet Still developing Well developed Walk up and down steps with alternating feet* Has not started yet Still developing Well developed Jump off a low step, landing on two feet* Has not started yet Still developing Well developed Throw a ball or another object* Has not started yet Still developing Well developed Catch a ball, trapping against own body* Has not started yet Still developing Well developed Kick a ball forward by stepping to it or running up to it* Has not started yet Still developing Well developed III. Language DevelopmentLanguages* English Spanish Other language Addtional LanguagePlease specify the additional language Please write the examples in the language that your child is speaking at home. If the language is other than English or Spanish, please provide a translation. Give us 3 examples of directions that you gave your child today that they were able to understand and follow the request*List 20 words that your child used today*Give us 3 examples of sentences that your child said today IV. Fine Motor Skills Before answering these questions, you might want to do one of the following: Give your child a pair of scissors and a piece of paper with a circle, square and triangle already drawn on the paper. Ask: “Cut out the circle. Cut out the square. Cut out the triangle.” Give your child play-doh and a small rolling pin. Ask: “What can you make with the play-doh? Show me how you can make it all by yourself.” Please choose as many of these fine motor skills as you would like by circling one descriptor. (Choose at least 1)Cuts along a straight line* Has not started yet Still developing Well developed Cuts along a curved line* Has not started yet Still developing Well developed Squeezes, rolls and pokes play-doh to form an object* Has not started yet Still developing Well developed V. LiteracyLanguage Literacy English Spanish Other Please specify language Before answering these questions, you might want to do one of the following: Place cards that you have made with all the letters from your child’s name on the table, in random order. Pointing to different letters. Ask: “Can you name this letter?” Gather a stack of your child’s favorite books. Ask: “Which book would you like to read.” (Let your child pretend read) Read a book to your child. Ask: “Tell me what happened in the story.” -or- “What did you learn from this book?” Please choose as many of these literacy skills as you would like by circling one descriptor. (Choose at least 2) Recognize and names at least 3 letters in own name* Has not started yet Still developing Well developed Show understanding that text is meaningful and can be read* Has not started yet Still developing Well developed When pretending reading, begin at the front and turn pages from front to back* Has not started yet Still developing Well developed Retell some events or information from a familiar story* Has not started yet Still developing Well developed VI. Mathematics Before answering these questions, you might want to do one of the following: Ask: “Start counting from 1, I will tell you when to stop.” (Place 9 small objects on the table) Ask: “How many objects are there?” (Give your child a pencil/piece of paper) Ask: “Write the numbers from 1 – 10.” (Give your child a pencil/piece of paper) Ask: “Draw a circle. Draw a square. Draw a triangle.” Please choose as many of these mathematics skills as you would like by circling one descriptor. (Choose at least 2) Count with accuracy from 1 to 10* Has not started yet Still developing Well developed Count with accuracy each object from 1-9* Has not started yet Still developing Well developed Write the numbers from 1-10 with accuracy. (Reversals are acceptable)* Has not started yet Still developing Well developed Draw a circle, square and triangle* Has not started yet Still developing Well developed VII. Additional Information about your childHas your child's pediatrician or teacher spoken to you about any developmental difficulties?*Has your child's pediatrician or teacher ever spoken to you about any concerns*Has your child been diagnosed with any of the following? Autism or Autism Spectrum Disorder Development Disability Speech articulation or Language delay Cognitive Disability Physical Disability Behavioral or Emotional Disability ADHD or ADD Sensory Processing Disorder Vision Disability Hearing Disability Learning Disability Has your child's pediatrician, specialist or teacher ever suggested that your child be evaluated for any of the disabilities listed above?* Yes No Please explainIs there anything else that you would like to tell us about your child? Δ
