PK3 Admissions Questionnaire

Please answer the following questions about your child to help us understand their preparedness for our PK3 program. For each item below, indicate whether your child is able to perform the activity listed regularly, sometimes, or not yet.

Parent's Name Parent's Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Student's Name Student's Name First Last
Birthdate Birthdate / MM / DD YYYY
Can name familiar items (ex. tree, table, book)

Can name familiar items (ex. tree, table, book) Yes, regularly Sometimes Not Yet
Understands the idea of “mine” and “his” or “hers”

Understands the idea of “mine” and “his” or “hers” Yes, regularly Sometimes Not Yet
Can name familiar items (ex. tree, table, book)

Can name familiar items (ex. tree, table, book) Yes, regularly Sometimes Not Yet
Can identify body parts such as eyes, nose, hair, feet, etc.

Can identify body parts such as eyes, nose, hair, feet, etc. Yes, regularly Sometimes Not Yet
Understands words like “in,” “on,” and “under”

Understands words like “in,” “on,” and “under” Yes, regularly Sometimes Not Yet
Says their first name, age, and gender when asked

Says their first name, age, and gender when asked Yes, regularly Sometimes Not Yet
Says words like “I,” “me,” “we,” and “you” and some plurals (cars,
dogs, cats)

Says words like “I,” “me,” “we,” and “you” and some plurals (cars,
dogs, cats) Yes, regularly Sometimes Not Yet
Can carry on a conversation using sentences

Can carry on a conversation using sentences Yes, regularly Sometimes Not Yet
Can work toys with buttons, levers, and moving parts

Can work toys with buttons, levers, and moving parts Yes, regularly Sometimes Not Yet
Plays make-believe with dolls, animals, and people

Plays make-believe with dolls, animals, and people Yes, regularly Sometimes Not Yet
Does puzzles with 3 or 4 pieces

Does puzzles with 3 or 4 pieces Yes, regularly Sometimes Not Yet
Copies a circle with a pencil or crayon

Copies a circle with a pencil or crayon Yes, regularly Sometimes Not Yet
Turns book pages one at a time

Turns book pages one at a time Yes, regularly Sometimes Not Yet
Builds towers of more than 6 blocks

Builds towers of more than 6 blocks Yes, regularly Sometimes Not Yet
Screws and unscrews jar lids or turns door handle

Screws and unscrews jar lids or turns door handle Yes, regularly Sometimes Not Yet
Can run and climb

Can run and climb Yes, regularly Sometimes Not Yet
Walks up and down stairs, one foot on each step

Walks up and down stairs, one foot on each step Yes, regularly Sometimes Not Yet
Can put on and take off shirt or jacket

Can put on and take off shirt or jacket Yes, regularly Sometimes Not Yet
Takes turns in games

Takes turns in games Yes, regularly Sometimes Not Yet
Follows instructions with 2 or 3 steps (i.e. put the toy down and get
a book)

Follows instructions with 2 or 3 steps (i.e. put the toy down and get
a book) Yes, regularly Sometimes Not Yet
Does your child talk well enough for strangers to understand most of the time?

Does your child talk well enough for strangers to understand most of the time? Yes No
Is your child fully potty-trained?

Is your child fully potty-trained? Yes No
If you answered no, please provide information about level of training (frequency of accidents, time spent in diapers/pull-ups, etc.)

Students entering St. Anne-Pacelli Catholic School’s PK3 program are required to be fully potty-trained. There are no changing
facilities in the PK3 classrooms.
Is there anything else we need to know about your child?
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