This information allows us to better understand your child’s developmental and educational needs. Thank you for helping us get to know your child a little better.
Basic Information
Name
*
First Name
Last Name
Primary Language of Child
*
Primary Language of Parents
*
Birth and Infancy
Is there any information about your child’s birth/infancy which you think would help the teacher more fully understand your child, for example, premature birth, birth complications, illnesses, adoption?
*
Did your child experience any developmental delays that required Early Intervention Services?
*
Eating Habits
Special characteristics or difficulties, including allergies or sensitivities:
*
Eating Speed
Slow
Fast
Sleeping Habits
When does your child go to bed?
What time does your child typically wake?
Nightmares
Please Select
Never
Occasionally
Frequently
Bed Wetting
Please Select
Never
Occasionally
Frequently
Uninterrupted Sleep
Please Select
Never
Occasionally
Frequently
Child sleeps in
Own room
Shared room with sibling/s
Family bed
Family / Home
Please list household members
Please list all household members, their relationship to the student, and the ages of other children in the house.
*
Does your child have siblings living in a different home?
*
Yes
No
please list names and ages
*
How do you discipline your child?
*
Please describe your child’s schedule on a typical day
*
Have there been significant changes in family (death, illness, divorce/separation, moves, etc.)
*
Previous Educational Experiences
Please list any schools your child has previously attended?
*
Has your child received a specialized evaluation, such as educational / psychological, hearing, speech, etc.?
*
Yes
No
Has your child received any Academic Intervention Service (AIS) or tutoring?
*
Yes, in the past
Yes, currently
No
Does your child have an Individualized Education Plan (IEP)?
*
Yes
No
Social Relationships
How would you describe your child?
*
How is your child in a social setting with peers?
*
Favorite activities
Fears
Describe the role that media plays in your child’s life
*
Hours of media exposure (TV, computer, video, electronic games, radio) daily
*
How are you hoping school will affect your child?
*
Is your child up-to-date in their immunizations?
*
Yes
No
Not sure
Comments
Is there anything else you would like us to know about your child?
*
Parent / Guardian 1 Signature
*
Parent / Guardian 2 Signature
Submitter's Email
*
example@example.com
Type a question
Submit
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