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Sage Parent Referral, Rating Form & Permission to Screen
Student's Name
*
First Name
Last Name
Parent or Guardian Name
*
First Name
Last Name
Teacher's Name
School Student Attends
*
Please Select
Barbieri Elementary
Brophy Elementary
Dunning Elementary
Hemenway Elementary
King Elementary
McCarthy Elementary
Potter Road Elementary
Stapleton Elementary
Wilson Elementary
Cameron MS
Fuller MS
Walsh MS
Grade Student is In
*
Please Select
1st
2nd
3rd
4th
5th
6th
7th
8th
Please state your agreement about what you see in your child.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My child is imaginative and creative.
My child can be stubborn or assertive
My child has a mature or unique sense or humor
My child is easily bored with routine tasks
My child is curious and likes to investigate
My child asks many questions about many topics
My child enjoys working with complex toys, games, kits, robots, or putting things together
My child learns about topics of personal interest rapidly and in-depth
My child demonstrates a high level of sensitivity
My child prefers to be with adults or older peers
My child can be a perfectionist and gets upset making mistakes
Calculation
Please share anything else you would like us to know about your child.
Email
*
example@example.com
My signature confirms that: · I am the parent or legal guardian of the student. · I consent to my student participating in the remote administration of the assessment using the platforms and processes specified by school administration. · I consent for my child to participate in Sage Pullout Services if a need is identified. · I understand and agree to follow all policies and procedures specified for this assessment. · I further acknowledge that my signature, verbal consent, or electronic signature is legally binding.
*
Submit
Should be Empty: