Fillable FAMILY INFORMATION FOR STEP UP TO QUALITY PROGRAMS (Mount Saint Joseph College)

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FAMILY INFORMATION FOR STEP UP TO QUALITY PROGRAMS (Mount Saint Joseph College)

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The FAMILY INFORMATION FOR STEP UP TO QUALITY PROGRAMS (Mount Saint Joseph College) form is 3 pages long and contains:

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  • 48 check-boxes
  • 34 other fields

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Ohio Department of Job and Family Services
FAMILY INFORMATION
FOR STEP UP TO QUALITY PROGRAMS (SUTQ)
Child's Name (Last)
(First)
Nickname (If any)
By providing complete information about your child, you will be assisting staff in creating a positive experience for him/her while in
care. List any information about your child's habits, abilities or personality that you feel will be helpful to the staff while caring for
your child.
Who is in the child's immediate family?
Who lives at home with your child?
What is the primary language spoken in your child’s home?
Are there any special family arrangements, such as shared parenting, living in two homes, or custody specifications, etc.?
Additional Details?
Are there any changes or transitions that your child has recently experienced or is experiencing? (moved from crib to bed,
divorce, new home, death of family member, friend or pet) Additional Details?
Are there any cultural or religious practices of your family we should be aware of? (Dietary restrictions, clothing, head coverings,
etc.)
Do you have any pets at home? If so, what are they and what are their names?
Has your child had a previous care arrangement? Yes or No Additional Details? (Center based, in home, with family,
with parents, etc.)
My child drinks milk, formula, juice or water. (Check all that apply)
How much and how often?
Does your child have any favorite foods?
Does your child dislike any foods?
Are there any foods your child should not be fed? (Licensing requires documentation be completed for children with food
allergies and/or dietary restrictions)
JFS 01511 (Rev. 10/2014) Page 1 of 3
Reset Form
Please check all of the words that best describe your child’s personality and behavior
active adventurous affectionate anxious bossy bright busy calm cautious cheerful
content creative curious easily-angered emotional energetic excitable friendly gives-in-easily
happy hesitant insecure jealous likes structure/routines loud loving mellow outgoing
prefers adult attention quiet sensitive serious shares-well social spontaneous stubborn tentative
other:
Are there additional personality and behavior characteristics that would be useful to know about your child?
Are there things that frighten your child? If so, how does he/she react and what do you do to comfort him/her?
What routines/actions or items do you use to comfort your child?
What causes your child to feel angry or frustrated?
What methods do you use to respond to your child’s negative behavior?
Does your child use any special comfort or support items that help him/her go to sleep? If so, what?
What is your child’s mood upon waking? (happy, grouchy, clingy, slow to awaken)?
My child sits in a high chair, booster, child size chair or adult size chair. (Check the one that applies.)
Is your child toilet trained? If not, have you started the toilet training process? Please explain the process used.
Does your child need assistance when using the toilet? If so, how?
What words, gestures or signs does your child use if he/she needs to use the bathroom?
What time does your child normally go to bed at night and wake up in the morning?
What time(s), and for how long, does your child usually nap?
JFS 01511 (Rev. 10/2014) Page 2 of 3
Does your child have trouble sleeping (Night terrors, trouble going to sleep, etc.)? Please explain.
What might you and/or your child be anxious about as he/she starts in this program?
What are you and/or your child excited about as he/she starts in this program?
What are your expectations of this program?
What other information would be helpful for the staff caring for your child to know?
Parent/Guardian's Signature
Date
JFS 01511 (Rev. 10/2014) Page 3 of 3
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FAMILY INFORMATION FOR STEP UP TO QUALITY PROGRAMS (Mount Saint Joseph College)

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Completed 24 August 2020

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