Children with Exceptionalities Form
Parent/Guardian's Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
1. Tell us about your child's personality.
*
2. Tell us about your child's exceptionality (extent of disability, allergies, physical limits, stamina, medical needs including medications, etc.)
*
3. What are your child's strengths? What do they enjoy doing for fun, or are interested in?
*
4. What are your child's dislikes? Any activities that they dislike or things that are a cause of stress?
*
5. Describe how your child has been best supported previously? Does your child have a support worker? What is their role?
*
6. How does your child follow direction? Does your child have a tendency to wander away / run away from their group?
*
7. How does your child get along with other children? How does your child get along with other adults / leaders / teachers?
*
8. What programs are you planning to register your child for?
*
9. Please tell us about any significant life events that we should be aware of that may have an impact on their participation or behavior (e.g., recent loss of a family member, friend, or pet, move, divorce, etc.)?
*
10. Is there anything else you would like to know about your child or information / resources about your child's particular condition that you would like us to be aware of? Please describe.
*
Submit
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