Parent Questionnaire – PK3 Parent Questionnaire – PK3 Parent Questionnaire – PK3 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 Balances self when bending over to pick up objects* Has not started yet Still developing Well developed Throw a ball or another object by pushing it with both hands.* 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 SkillsBefore answering these questions, you might want to do one of the following: Get bubbles and blow them. See if your child can point to them and poke them. Give your child several containers and sand. Ask: “Can you fill up these containers?” Give your child some paper. Ask: “Can you tear this up for me?” Please choose as many of these fine motor skills as you would like by circling one descriptor.Poke and point at objects* Has not started yet Still developing Well developed Fill a container with sand by using scoops and cups* Has not started yet Still developing Well developed Tear paper into pieces* Has not started yet Still developing Well developed V. Learning Before answering these questions, you might want to do one of the following: Gather a collection of objects such as 4 red blocks, 4 blue blocks”or 4 small seashells and 4 large seashells. Place in a basket with them mixed up. Take out 2 red blocks or 2 small seashells. Ask: “Can you find some like mine?’ Get a few books to read. As you read, Ask: “Point to the bear (or person, object in story).” Please choose as many of these learning skills as you would like by circling one descriptor. Sustain interest in working on a task, especially when adults offer suggestions, questions or comments* Has not started yet Still developing Well developed Matches similar objects* Has not started yet Still developing Well developed Recognizes people, objects and animals in pictures or photographs* Has not started yet Still developing Well developed VI. LiteracyLanguage Literacy English Spanish Other Untitled Before answering these questions, you might want to do one of the following: Gather a stack of your child’s favorite books. Ask: “Which book would you like to read.”. (Read the book with your child and talk about the story.) Gather a piece of paper and a pencil. Ask: “I am going to write a letter today to _______. I want you to write your own letter to ____.” Please choose as many of these literacy skills as you would like by choosing one descriptor. Enjoy pretend writing – scribble writes deliberately* 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 VII. 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.” (Gather toy cars, blocks and toy houses) Ask: “Put the car next to the block, put the green car between the two houses.” (Get a shape sorter or find shapes in the house – triangle, circle, square.) Ask: “I have a circle. Can you find a circle?” Please choose as many of these mathematics skills as you would like by circling one descriptor. Pretend count from 1 to 10, not necessarily in order* Has not started yet Still developing Well developed Follow simple directions related to proximity (besides, between, next to)* Has not started yet Still developing Well developed Matches two similar shapes* Has not started yet Still developing Well developed VIII. 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
