To be completed by the end of Week 2. Please complete a
separate form for each child that you are hosting. |
Family Name: |
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City, State |
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Your E-mail: |
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Summer Miracles Child
First Name: |
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Summer Miracles Child
Last Name: |
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Date Child Entered
Your
Home: |
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1. What
have you noticed that has changed about the child since you wrote your
first evaluation? |
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2. How, if
at all, is the child's visit affecting your family including your
children, if any? |
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3. How are things going
on compared to week 1? (Please describe briefly your hosting experience at
this point and choose one answer from the following options). |
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It is getting more and
more challenging
It is getting
less enjoyable and more challenging
It is equally
enjoyable and challenging
It is getting
less challenging and more enjoyable
It is getting more and
more enjoyable |
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4. How would you describe the
child's gross and fine motor skills? (Is the child well coordinated or
does the child trip and stumble a bit, can he/she write/draw for a long
period of time or does he/she tire of this quickly? In addition, please
choose one answer below that best describes your child's motor
development). |
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Motor Development:
poor
underdeveloped
satisfactory
well developed
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5. What has been the
best part of the visit? |
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6. What has been the
most challenging part of this visit? |
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7. What information
could have helped you manage these challenges? |
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8. Is there any
assistance you would like/need to get from the program? |
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9. Are there any issues you would like to
discuss with Kidsave or a Social Worker? |
Kidsave Representative should call
Social Worker should call |
Best Time of Day to Reach You? |
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Please send us
photos of the child. Send to Kidsave, 5165 MacArthur Blvd., NW,
Washington, DC 20016. |
| A copy of this completed questionnaire will be sent
to Kidsave. You will also receive a confirmation copy by return
E-mail for your records. |
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(Click submit to send.) |
