Warehouse worker

FAMILY INTERVIEW TEACHER TEMPLATE: TELL ME ABOUT YOUR CHILD!

This is an optional form you can use to conduct your family interviews.

DEMOGRAPHIC INFORMATION

Child’s Name:

Age: Birthdate:

Address:

Mom or Guardian’s Name:

Home #: Cell #:

Email:

Dad or Guardian’s Name:

Home #: Cell #:

Email:

SCHOOL INFORMATION

How will your child get to and from school?

Is your child repeating Kindergarten? yes no

Does your child have an Individualized Education Plan? yes no

Does your child receive any support services?

Speech yes no

Physical Therapy yes no

Early Intervention yes no

Other yes no

If yes, what services?

PREK INFORMATION

Did your child go to PreK? yes no

If yes, what type?

Child Care Center

Name of the school?

Head Start

Name of the school?

PA PreK Counts or Bright Futures

Name of the school?

Locally Funded PreK (includes PHL PreK)

Name of the school?

Home Care - Family Child Care (Licensed; care in a home with 4-6 other children)

Home Care - Relative/Neighbor Child Care (Provider with 1-3 children)

Home Care - Home-based Care (Cared for at home with a nanny, friend, etc.)

OTHER INFORMATION

Does your child have any health concerns? If yes, what are they?

What are your child’s strengths (academic and non-academic)?

What are your child’s areas of concern (academic and non-academic)?

Is there an academic area in which your child might need extra help?

What else would you like me to know about your child?

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