CONFIDENTIAL FORM
PRESCHOOL through Kindergarten

Please print this page and turn it in to the school office.

Child’s Name _________________________________________________________
        Last            First          Middle            Name Used

Current Grade____________    Grade applying for________      Male___ Female___
Date of Birth ______________    Present Address _____________________________
Home Phone _________________                 ________________________________

Allergies _______________________________________________________________
Mother’s Work Ph. ___________________ Father’s Work Ph. __________________
Mother’s Cell Ph. ____________________  Father’s Cell Ph. ____________________
Other Numbers __________________________________________________________
Other emergency names and phone numbers _________________________________
Relationship to your child _________________________________________________

    Please complete the following information, understanding that it will be confidential. Your child is very precious to us; and therefore, it is our desire to meet his/her needs to the best of our ability. The information below will enable us to better understand your child. Thank you for helping us.

Mother’s Information:
    Name _________________________     Married/Single/Divorced
    Address _______________________        
    Profession _____________________        e-mail address(es):
    Firm Name ____________________        ____________________________
    Education Level _______________        ____________________________

Father’s Information:
    Name ________________________        Married/Single/Divorced
    Address ______________________
    Profession ____________________        e-mail address(es):
    Firm Name ___________________        _____________________________
    Education Level _______________        _____________________________

School applicant is attending or last attended ___________________________________
                            School Name        School District
_______________________________________________________________________
     School Address            City        State    Zip Code        Phone

Was this a  positive school experience for your child? ____________________________

Has your child ever been retained?  _______Yes  ______No
Comments:______________________________________________________________
                    
Has your child ever had difficulty in reading or math? ____________________________
________________________________________________________________________

Has your child ever been diagnosed for or received special help for a reading or learning difficulty?    ______Yes   ______No
Comments_______________________________________________________________________________________________________________________________________________________________________________________________________________

Please circle the answer that best describes your evaluation of your child.

Academically do you consider your child:  above average    average    below average

In peer relationships do you consider your child:  above average   average   below average

Does he/she make friends easily?   ______Yes      ______No

Emotionally do your consider your child:  above average    average    below average

How does your child relate to you as the parent?  
    overly dependent    overly independent    comfortably

How would you are your child’s obedience to you on a scale of 1-10?
                   (10 being very obedient)
    1    2    3    4    5    6    7    8    9    10

How well does your child respond to other authority figures? (Grandparents, Sunday School Teachers)
    compliant                reluctant                      defiant

On a scale of 1 - 10 how does your child feel about school?
            (10 being enjoys/looks forward to school)
    1    2    3    4    5    6    7    8    9    10

Does your child have any specific habits? (thumb sucking, nail biting, hand washing, teeth grinding, snapping) _______________________________________________________________________

Siblings: (names and ages)__________________________________________________
    How does your child relate to siblings? __________________________________

What other adults live in your home? _________________________________________

With whom does your child stay when mother/father is away? _____________________
                    
Right/Left Handed _________

Favorite toys: ___________________________________________________________

Special talents/interests: ___________________________________________________

How often does your child watch TV/videos? __________________________________

What is your child’s favorite TV program/video? _______________________________

Does your child sit and listen to stories? ___________________ Like books? _________

What kind? _____________________________________________________________

Can your child read? _________________ If not, does he/she show interest? _________

Does your child enjoy music/singing? ________________ Types of music? __________

Pets? (names/kind) _______________________________________________________

Does your child attend Sunday School? _____________ Where? ___________________

Any other activities outside the home? ____________________________________

What is your child’s favorite color? ________ Number? ________ Game? _______

What are some experiences which have influenced your child (trips, illnesses, accidents, moves, job loss, deaths, divorce, etc.)? _____________________________________
____________________________________________________________________
____________________________________________________________________

Does your child have a daily routine and how does he/she react to changes in routine?
____________________________________________________________________

Does your child need help going to the bathroom? Explain _____________________

What are some chores/responsibilities your child has around the house?
____________________________________________________________________

Should we be made aware of anything which frightens your child?
_____________________________________________________________________

How do you discipline your child?
_____________________________________________________________________
                    3

What is his/her reaction to your discipline?
_____________________________________________________________________

Have you detected or suspected difficulties in hearing? _____ speech? _____ sight? ____
Explain ________________________________________________________________

How did you first learn of NCA? (check only one)

___Student(s) currently enrolled     ___Alumni     ___Newspaper or magazine
___ Minister     ___Parents of NCA student     ___Telephone book     ____Online search
___ Facebook

Did you explore our website?  ____Yes         ____No
Are you an NCA Facebook fan?   ____Yes      ____No

What most influenced you to apply to NCA?
___Academic Reputation     ___Christian Worldview     ___Location   ___Teaching Staff     
___Recommendation of NCA families     ___Desire to attend a private school
___Website Information

What school district do you currently reside in? (circle one)
    Nacogdoches: TJR      Brooks-Quinn Jones      Raguet      Fredonia     
             Nettie Marshall     Carpenter     Mike Moses      McMichael
    Douglass    Martinsville        Woden        San Augustine        Lufkin
    Central Heights    Cushing    Central        Chireno    Etoile


Thank you for sharing this information about your child. Please use the rest of this sheet, and the back if you need it, to tell us anything else you want us to know about your child. Is your child imaginative, artistic, talkative, temperamental, jealous, independent, happy, etc.?
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