Enrichment and Learning Support Programs

Child Information Sheet

About the Child

Name *

Nickname *

Date of birth *

Age *

Grade Level *

School *

The following questions are given to help us choose books that will be relevant to your child. The more we know about them, the better we will be able to read stories that will reflect their life experiences.

Interests

Activities your child enjoys *

Does your child enjoy reading with you? *

Does your child enjoy reading independently? *

If you answered yes to one of the two questions, what are some of the books your child enjoys reading? *

Family Setup

Family Setup *

School History

Is there any significant information that you would like to share with us about your child's experiences in school? For example, are there certain struggles or difficulties you feel like will be important for us to know? *

Therapy Services

Does your child receive therapy services? *

About the home

Living Address:

Father's Information

Father's Full Name

Father's Citizenship *

Father's Profession *

Father's Mobile Number *

Father's Email *

Mother's Information

Mother's Full Name

Mother's Citizenship

Mother's Profession

Mother's Mobile Number

Mother's Email

Siblings

Please input the name age and of your child's siblings. *

Name & Age
Name & Age
Name & Age
Name & Age
Name & Age

In Case of Emergency

Guardian's Name *

Guardian's Relationship to Child *

Guardian's Home Number *

Guardian's Mobile Number *

Form filled out by:

Name of person that filled out this form: *

Signature: *

Clear

Date Completed: *