Personal History

Personal History Record St. Mark’s Preschool

Child’s Name(Required)

Date(Required)

Address(Required)

Zip(Required)

Home phone:(Required)

Primary Email Address(Required)

Secondary Email Address

Birth Date(Required)

Age(Required)

Sex(Required)

Father’s Name(Required)

Father’s Place of Employment(Required)

Occupation(Required)

Business Phone(Required)

Cell Phone(Required)

Mother’s Name(Required)

Mother’s Place of Employment(Required)

Occupation(Required)

Business Phone(Required)

Cell Phone(Required)

Primary phone number and number that will be put on the class list(Required)

Other Children in the Family: Brothers(Required)

Ages(Required)

Sisters(Required)

Ages(Required)

Other Adults living with the Family:(Required)

Relationship(Required)

General Health of all members of the Family: Mother(Required)

Father(Required)

Others(Required)

What contacts does child have with other children(Required)

Is child left-handed(Required)

Problems with toilet habits (if any)

Fears(Required)

Food Allergies(Required)

Is child allergic to bee sting(Required)

List any other allergies(Required)

Does your child have any sort of court order affecting his or her life?(Required)

Is there anything else you would like us to know about your child?(Required)

Child’s physician(Required)

Phone(Required)

People to contact if parents cannot be reached: (Must be local)

1. Name(Required)

Address(Required)

Phone(Required)