“We accept funds from the New York State Department of Social Services.”
NYSDSS
Interview Form
Child's Full Name
(Required)
Date of Birth
MM slash DD slash YYYY
Home Address
(Required)
Home Phone Number
Mother's Name
(Required)
My Child Calls Me
Cell Phone Number
Email Address
(Required)
Occupation
Work Address
Work Phone Number
(Required)
Father's Name
(Required)
My Child Calls Me
Cell Phone Number
Email Address
(Required)
Occupation
Work Address
Work Phone Number
(Required)
Sibling
Age
Parents Marital Status
Does the child live with both natural parents?
Yes
No
Emergency Contact Information
Name
Phone Number
Relation to Child
Pediatrician
Address
Phone Number
Allergies
About Your Child
For snack my child likes to eat:
For lunch my child likes to eat:
My child loves to:
When child is upset, what calms him/her down?
Language(s) spoken at home:
Language(s) spoken by child:
How does your child respond to new situations:
Any other information you would like us to know about your child:
How did you hear about our Preschool?
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Name
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