Spanish (Latin America)
Sage Parent Referral, Rating Form & Permission to Screen
Parent or Guardian Name
School Student Attends
Potter Road Elementary
Grade Student is In
Please state your agreement about what you see in your child.
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
Please share anything else you would like us to know about your child.
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.
Should be Empty: