A WORD TO FAMILIES: Your complete answers to the following questions will help us better understand your child and determine if they would be eligible to attend our program FREE. 1. Describe a typical day for your preschool child. 2. Describe any concerns (past/present) about your child’s growth or development (physical, social, emotional, language, etc.) 3. Were there any complications during the birth of your child? 4. Has your child had any surgery, hospitalizations, or medical procedures? Does your child take any medications regularly? Please explain. 5. Has anyone in the family (parents/siblings) had difficulty or challenges in school? If yes, please describe. 6. Does anyone in the family receive special health and/or education services? If yes, please describe. 7. Do you currently find yourself in any of the situations below: ____Children and immediate family have moved in with other relatives or friends ____ Foster child, or living in transitional housing through a shelter, or in a temporary residence facility ____ Living in a welfare sponsored room or rooms in a hotel/motel ____ Living in a makeshift shelter such as a car, tent, abandoned building, etc., or living on the street 8. Do you have a custody/visitation agreement for your preschool If yes, please describe. Parent/guardian Signature________________________________________ Date _________________ GSRP Staff Signature_______________________________________ Review Date________________
A WORD TO FAMILIES: Your complete answers to the following questions will help us better understand your child and determine if they would be eligible to attend our program FREE. 1. Describe a typical day for your preschool child. 2. Describe any concerns (past/present) about your child’s growth or development (physical, social, emotional, language, etc.) 3. Were there any complications during the birth of your child? 4. Has your child had any surgery, hospitalizations, or medical procedures? Does your child take any medications regularly? Please explain. 5. Has anyone in the family (parents/siblings) had difficulty or challenges in school? If yes, please describe. 6. Does anyone in the family receive special health and/or education services? If yes, please describe. 7. Do you currently find yourself in any of the situations below: ____Children and immediate family have moved in with other relatives or friends ____ Foster child, or living in transitional housing through a shelter, or in a temporary residence facility ____ Living in a welfare sponsored room or rooms in a hotel/motel ____ Living in a makeshift shelter such as a car, tent, abandoned building, etc., or living on the street 8. Do you have a custody/visitation agreement for your preschool If yes, please describe. Parent/guardian Signature________________________________________ Date _________________ GSRP Staff Signature_______________________________________ Review Date________________