Information Form

Please fill out the information completely. Fields marked with a * are required.

Child's Name *

First

Last

Child's Nickname *

Session *

Age at Potty Training *

Please list any siblings and their ages in parenthesis (…)

Sibling 1 *

Sibling 2 *

Sibling 3 *

Sibling 4 *

Please list any other family members living in household and their relationship in parenthesis (…)

Family Member 1 *

Family Member 3 *

Family Member 2 *

Family Member 4 *

Does your child have special fears? *

Please list any food or drink ingredients your child should not have. *

Do you have concerns about your child’s development? *

What languages, if any, are spoken at home other than English? *

What time does your child wake up? *

Does your child nap? *

What time does your child go to bed? *

If yes, when does your child nap? *

What method(s) of behavior control do you use at home? *

How does your child respond to this correction? *

What are some of your child’s favorite activities? *

Has your child gone to preschool or daycare before? (If yes, where?) *

What would you like to be included in your child’s preschool program? *

Age when he/she began walking *

Age when he/she became potty trained *

Age when he/she wiped self after potty *

Please explain any stressful experiences, if applicable, which may affect your child's behavior (divorce, death, family illness, etc) *

Describe any other symptoms/illnesses your child experiences: *

Please list any allergies, if applicable, that affect your child and describe the reaction symptoms of which we should be aware *

MEDIA RELEASE: I grant to Kiddie Kampus, Upland United Methodist Church and its children’s ministry, employees, and volunteers the right to take photographs, video, and/or electronic images of any member of my family in the children’s ministry environment. I authorize the aforementioned entities to copyright, use, and publish (i.e. Facebook) the photographs, video, and/or electronic images in print and/or electronically—with or without our names—for any lawful purpose to highlight and promote Kiddie Kampus, Upland United Methodist Church and its children’s ministry.

I agree to the above Media Release statement *

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