Fillable Family Profile Family Profile 2010

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Family Profile Family Profile 2010

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1
FRESNO STATE PROGRAMS FOR CHILDREN
FAMILY PROFILE
Dear Parents:
We are asking you to share information and comments with us about your family, culture, beliefs
and experiences. Learning about your family will help us enhance your child’s education,
develop a positive relationship with you and your child, and meet your child’s and family’s
needs.
1. Child’s Name _____________________ Nickname(s) _________________________
2. Birthdate _____________________
3. Allergies ___________________________________________________________________
4. Does your child take any long term prescribed medication(s)? If yes, please describe:
___________________________________________________________________________
5. Does your child have any special needs or chronic illnesses, (e.g. asthma, seizures, feeding
needs.)? ___________________________________________________________________
___________________________________________________________________________
_________________________________________________________________________
6. Are there special instructions that will help the teacher attend to any special needs your child
may have? _________________________________________________________________
___________________________________________________________________________
7. Child’s living arrangement: child resides with: (Please indicate all that apply/ explain shared custody)
Both parents _____________________ Grandparents _________________________
Father _____________________ Mother _________________________
8. Visitation schedule (if any) ____________________________________________________
9. Is this arrangement court ordered? Yes – No (Circle one)
10. Has anyone of significance to the child been away for a long period of time? Yes – No
(Circle one) If yes, please explain: ______________________________________________
11. Child’s home setting: House – Apartment – Rural – Urban (Circle one)
12. Does child have his/her own room or does the child share a room? Explain: ______________
___________________________________________________________________________
13. What is your child’s normal bedtime? ____________________________________________
14. What is your child’s normal wake- up time? _______________________________________
15. Does your child have any special sleep-time objects? ________________________________
16. How many times has your child moved since birth? _________________________________
Please specify _______________________________________________________________
2
17. Primary language spoken to the child ____________________________________________
18. If there are any holidays that are not to be celebrated with your child, please specify
___________________________________________________________________________
19. Does your child have any pets? Yes – No (Circle one) If yes, please indicate type of pet(s)
and pet name(s) _____________________________________________________________
20. Does your child have imaginary playmates? Yes – No (Circle one) If yes, please explain
___________________________________________________________________________
21. List some of your child’s favorite play items and books: _____________________________
___________________________________________________________________________
22. At which meal is your child most hungry? ________________________________________
23. How many hours of tv does your child watch each week? ____________________________
24. List television program(s) your child watches ______________________________________
___________________________________________________________________________
25. Is your child toilet trained? Yes – No (Circle one) Comments: ________________________
___________________________________________________________________________
26. Specify child’s words for:
Urinating _______________________________________________________
Defecating ________________________________________________________
Genitals ________________________________________________________
PARENTS:
27. Mother’s Name _________________________________ Natural – Step – Adoptive – Foster
(Circle the one that applies mother-child)
28. Mother’s Age __________________________ Ethnic Origin ________________________
29. Employed: Yes or No Student: Yes or No
30. Father’s Name _________________________________ Natural – Step – Adoptive – Foster
(Circle the one that applies to father-child)
31. Father’s Age _____________________ Ethnic Origin _________________________
32. Employed: Yes or No Student: Yes or No
3
33. Please list other’s in the home. Include name and relationship to child. For siblings please
include the ages.
Name Relationship
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
34. Primary language spoken in the home? ___________________________________________
35. Religious preference(s) of the immediate family ____________________________________
36. What goals do you have for your child this year? ___________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
37. What are your child’s strengths? ________________________________________________
___________________________________________________________________________
___________________________________________________________________________
38. What are your child’s interests and preferences? ___________________________________
___________________________________________________________________________
___________________________________________________________________________
39. What are your child’s dislikes, fears or challenges? _________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
40. What are your observations about your child’s development: cognitive, language, physical
and emotional? ______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
4
41. What are your observations about your child’s social relationships with other children and
adults outside the family? _____________________________________________________
___________________________________________________________________________
___________________________________________________________________________
42. What is your family’s approach to discipline? _____________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
43. Are there other circumstances or considerations that the center staff should know about?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
44. What topics would you be interested in learning more about through discussion or
educational programs: child- rearing, child development, early education, family or any other
areas? _____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
45. In what other ways – programs, activities, etc. can the Fresno State Programs for Children
enhance your family’s life and your involvement with the university? ___________________
___________________________________________________________________________
___________________________________________________________________________
Parent Name (Printed) ______________________________
Parent Name (Signature) ___________________________________ Date __________________
Thank you for completing this questionnaire. The information you provided is confidential and is
available only to staff who work directly with you and your child and to administrators on an as
needed basis.
FP- revised 2010
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Completed 10 March 2020

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