Request for enrollment Step 1/9: General information about the child Leave this field blank General information about the child Name of child Last name (surname) Date of birth Sex M F Personal Identification Number Registered Residence - City Registered residence - Street, number, subnumber Planned month for enrollment Information about parents/guardians Relation to the child please write mother, father, ... Name of parent/guardian Last name (surname) of parent/guardian Telephone number Mobile number Email adress Relation to the child please write mother, father, ... 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 Please state 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 No 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 No 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 No 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 No 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 No 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 No State what kind Does child reject some types of foods Yes No 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 No State which foods Special note related to nutrition Please state 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 Please state Child needs diapers Yes No When does the child use them all the time during day sleep (nap) during night sleep Is child potty-trained Yes No 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 No How many months it started Child has crawled Yes No with how many months started Child walks independently Yes No 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 ex: car broom-broom, bear drinks... months Does child understand when others speak? Yes No Does child pronounce correctly grammar sounds of the croatian language only applies to child 3 years old and older Yes No Does the child have a change in tempo and rhythm when speaking? repeating, pausing, talking too fast... Yes No Does the child live in a multilingual environment? Yes No What is the primary language spoken at home? Social - emotional development of child Child has attended preschool, babysitting service, been to a playroom Yes No 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 No Which ex: pacifier, bottle, toy What is the easiest way to comfort child? Characteristics of child’s play, attention and knowledge Child, most often, likes to play with person, object ... 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 TV, cartoons, movies, playing video games ... 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? next save and continue later
