Learning Profile Survey

Child’s Name ________________________________________

Name child prefers to be called_____________________________________

Is your child potty trained? ____________________________

Child’s Ethnicity___________________________________________________

Name of Parents/Guardian(s):_____________________________________________

________________________________________________________________________

How do you prefer I contact you (Check one)?  E-mail ______  Phone________

E-mail address__________________________________________________________

Phone Number__________________________________________________________

Does your child have any known allergies or medical conditions? ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Who does your child live with? ____________________________________________

What language do you speak in the house?__________________________________

What are some activities you do with your child?_____________________________

________________________________________________________________________

________________________________________________________________________

Would you like to volunteer in the classroom?  Yes ___________  No _________

If you answered yes to the last question, when are you available?_______________

________________________________________________________________________

Any questions or concerns?________________________________________________

________________________________________________________________________

________________________________________________________________________