Request for enrollment

1. General information about the child
2. Information about parents/guardians
3. Information about the family
4. Information of health and developmental status of child
5. Needs and habits of a child
6. Motor and sensory development of child
7. Communication and language speaking development of child
8. Social - emotional development of child
9. Characteristics of child’s play, attention and knowledge

Leave this field blank

General information about the child

Name of child

Last name (surname)

Date of birth

Month
January
February
March
April
May
June
July
August
September
October
November
December
Nothing found

Day
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Nothing found

Year
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Nothing found

Sex

Personal Identification Number

Registered Residence - City

Registered residence - Street, number, subnumber

Planned month for enrollment

Month
January
February
March
April
May
June
July
August
September
October
November
December
Nothing found

Year
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
Nothing found

Information about parents/guardians

Relation to the child

Name of parent/guardian

Last name (surname) of parent/guardian

Telephone number

Mobile number

Email adress

Relation to the child

Name of parent/guardian

Last name (surname) of parent/guardian

Telelphone number

Mobile number

Email adress

Information about the family

With whom does the child live with

How long hasn't the child lived with both parents/guardians?

residing in another city

divorce

dissolved our of wedlock union

restraining order

fostering

guardianship

other

Is family in counseling with the center of social welfare

Yes

Navesti koje vrste

supervision of parental rights

Litigation of divorce

welfare services

ostalo

Please state the times your child would be at the preschool during the year

Child woulld arrive at

hours

Child would leave at

hours

Information of health and developmental status of child

Pregnancy

normal

high risk

other

Type of birth

Choose
natural
caesarean
vaccum

Birth

at weeks

Birth weight/height

Apgar score

Days spent in hospital

Condition of child before and after birth

normal

infection

wrapped umbilical cord

intracranial bleeding

given oxygen

incubator

other

Frequent acute and/or chronic sickness and condition

Please write if the child stayed in the hospital

Name of hospital

How many days

Reason for the stay

Difficulties due to separation

Yes

Navesti koje vrste

Child is being monitored or receiving therapy by specialist

ex: physical therapist, speech therapist, rehabilitator, psychologist, neuro pediatrician and others (please note: for the initial interview, it is necessary to bring all medical documentation)

Yes

What institution

What type of experts

What type of therapy was given

Child with special educational needs

(developmental disability, health difficulties and neurological damage, chronic sickness, elimination of nutrition, risk behavior, and so forth...) Pplease note , on the initial interview it is necessary to bring all relevant documentation to confirm the status and needs of the child

Yes

Which

impaired vision

hearing impairment

Intellectual disabilities

disabilities from the spectrum of autism

motor skill disorders

language/speech disabilities

specific disability in learning

Chronic illness

risk behaviour

special health needs

attention deficiency - hyperactive disorder

None of the mentioned above

If there is documentation which the child has

results and opinions of a sole expert

decision from social welfare

results and opinion of a specialized institution

opinion from the professional team of the preschool

medical and other results

Needs and habits of a child

Child is still breastfeeding

Yes

Form of consuming liquids

bottle

use of cup with help

use of cup independently

Form of consuming food

mushy

small pieces

solid

Feeding

independently

not independently

needs to be fed

Apetite

good

bad

selective

depends

excessive

Child has/had difficulties with chewing and swallowing

Yes

State what kind

Does child reject some types of foods

Yes

State which types

Elimination of nutrition

allergic on certain foods, celiac disease, intolerance, nutrition conditioned by metabolic disorders and other (Please note: on initial interview, necessary to provide medical documentation)

Yes

State which foods

Special note related to nutrition

Sleep pattern times

Night times

from to hours

Day time

first nap - from to hours

second nap - from to hours

How does child fall asleep

falls asleep independently

with pacifier

with bottle

breat fed

with toy

other

Child falls asleep

easy

with difficulty

Child sleeps

peaceful

restless

cries in sleep

screams

wakes up many times

On average how many times

Special note related to sleeping

Child needs diapers

Yes

When does the child use them

all the time

during day sleep (nap)

during night sleep

Is child potty-trained

Yes

started with months

Now child

goes independently to the toilet or potty

asks to be taken to the toilet

needs to be reminded

sits and doesn't defecate

refuses to go

does not independently defecate

other

If child is weaned off from diapers, does it happen

wets underwear in conscience state

wets underwear when sleeping

defecates in underwear

retention of bowel

none of the above

Special note related to diapers and defecation

Motor and sensory development of child

Child sits independently

Yes

How many months it started

Child has crawled

Yes

with how many months started

Child walks independently

Yes

with how many months started

Have you noticed any specific motor skill developments of your child from the following

clumsiness

falling frequently

stumbling

colliding into objects

tendency to injury

increased motor movement (lively)

walks on toes

doesn't like to move

None of the above - other

Does the child show hypersensitivity to environmental stimuli?

sound

touch

light changes

smell

taste

spinning

swaying (back-forth, side to side)

none of the above - other

Communication and language speaking development of child

Expression of child

gesture

cooing, babbling

with words

with sentences

You notice in your child

responds to their name

brings and shows interesting thing, toys

looks into your eyes

looks at you and checks how you will react

laughs when you laugh

imitates your moments, grimace, clapping

waves "bye-bye"

uses gestures to show

How many months old did the child say first word with meaning

months

How old was child when he/she said a full sentence

months

Does child understand when others speak?

Yes

Does child pronounce correctly grammar sounds of the croatian language

Yes

Does the child have a change in tempo and rhythm when speaking?

Yes

Does the child live in a multilingual environment?

Yes

What is the primary language spoken at home?

Social - emotional development of child

Child has attended preschool, babysitting service, been to a playroom

Yes

How did the child adjust

Separation from a close person is for the child

hard

no problem

has never been separated

Child has had contact with other children

rarely

occasionally

often

In contact with other children

observes other children

plays close to them

is shy

withdrawn

shows very little interest to play with other children

tries to include in play

cooperates well with other children

sometimes shows rudeness towards children (biting, pushing, fighting)

compassion

comforst

helps

willing to share, donate

In emotions, moods and habits of child

very disturbed when separated from parents

complains on stomach pain, headache similar

often resists requests

often says "no"

is angry, has outbursts of anger

shows jealousy

cries frequently

has respiratory affective crisis

shows sign of ticks

shaking of hands

unusual motion of hands near the face

nail biting

biting one self

swaying

hair twirling

hopping in place

spinning around one self

walking in a circle

shows fear of (please state)

none of the above - other

shows fear of:

Child usually carries an object

Yes

Which

What is the easiest way to comfort child?

Characteristics of child’s play, attention and knowledge

Child, most often, likes to play with

Child's attention span in play or activity

short time - often doesn't finish one game

short time - transitions to another game

easily interrupted by sounds or stimuli from the side

plays with one game for a long time

repeats same activity many times in a row

sometimes wanders in thoughts (daydreaming)

cannot evaluate

Precautions in behaviour

has no precaution

carelessly distances one self from parents and other familiar people

poorly estimates danger

climbs

puts small and inedible things in mouth

fearless

none of the above - other

Child spends time in front of screens watching

doesn't spend time in front of screens

television

mobile phone

personal computer, laptop, tablet

none of the above - other

Average time spent in front of screens

minutes

What is your child good at, what are your child’s strengths?

are you concerned with something related to the development and behavior of your child? If yes, what is the concern?

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