Child's Name
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First Name
Last Name
Birth Date
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MM
DD
YYYY
Sex
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Home Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/Guardian 1 - Name
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First Name
Last Name
Parent/Guardian 1 - Phone
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Country
(###)
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Parent/Guardian 1 - Email
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Does Parent/Guardian 1 live at the same home address as the child?
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Parent/Guardian 1 - Occupation
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Parent/Guardian 1 - Employer
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Parent/Guardian 2 - Name
First Name
Last Name
Parent/Guardian 2 - Phone
Country
(###)
###
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Parent/Guardian 2 - Email
Does Parent/Guardian 2 live at the same home address as the child?
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Parent/Guardian 2 - Occupation
Parent/Guardian 2 - Employer
Does your child have any daycare, preschool, or class experience? If so, please list and describe.
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Who provides your child with their daily care? (ex: parent, nanny, relative, specific daycare/preschool, etc.)
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Is your child toilet-trained? (This is not a requirement for enrollment, but limited spaces are available for non-toilet-trained children.)
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Does your child have allergies? If yes, please elaborate.
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Describe your child’s personality and current interests. Please elaborate and be as detailed as possible.
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Describe your child’s level of independence at home. (ex: gets dressed, puts shoes on, clears dishes, eats independently, cleans up toys, plays independently, etc.)
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How long is your child able to focus and engage on age appropriate tasks/activities? (ex: legos, puzzles, drawing, painting, gardening, etc.)
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Describe your child’s developmental strengths and challenges. Please elaborate and be as detailed as possible. (ex: consider social interactions, temperament, separation from caregivers, language/communication, milestones, etc.)
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How does your child show frustration/anger? Please elaborate and be as detailed as possible.
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How does your child react to you leaving them?
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How many hours per day (on average) does your child watch tv? What type of shows/movies?
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Does your child use a tablet or phone? If so, how many hours per day (on average)? What does your child do on it?
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Does your child play video games? If so, how many hours per day (on average)? What type of games?
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Do you have any concerns about your child’s development? Please elaborate and be as detailed as possible.
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What are your goals for your child's development? Please elaborate and be as detailed as possible.
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Has your child had a formal developmental evaluation and/or do they receive services privately or through early intervention?
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Is there anything else you would like us to know about your child that would help us understand him/her better?
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Please list all family members living at home and their relationship to your child. Please include the current schools and ages of siblings.
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Please list all languages spoken in your home and your child’s level of proficiency in each.
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How do you and your family spend time together? What type of activities do you enjoy together as a family?
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How did you hear about Casa de Luna?
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In what ways does Casa de Luna appeal to you?
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Is there anything else you'd like to add?
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