Personalized Learning Insights: Parent Questionnaire
We value your input in shaping a learning environment that best meets your child's unique needs. Please take a few moments to share your thoughts and insights about your child's educational journey and personal needs. Your responses will help us create tailored educational experiences that align with your family's values and your child's learning style. If you have multiple children please complete this questionnaire and include information for each child.
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
What is your child's name, age, and upcoming grade level? ( if you have multiple children please include information for each child)
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What are the top 3 priorities for your child's education?
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Emotional safety
Physical safety
Academic progress
Being at or above grade level
Following their passions
Igniting a passion for learning
Meeting state standards
Relationships and connections
Real-world applications
Exposure to diversity and inclusion for all
Other
How would a non traditional school setting benefit your child's educational goals?*
*
What do you see as your child's responsibility in their education?*
*
What do you see as your responsibility in your child's education?*
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What do you see as the school's responsibility in your child's educational journey?
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What behaviors/characteristics does your child exhibit when stressed/uneasy?What techniques work best for your child to regulate their nervous system? ( your answers here will help us to ensure our calming space has what your learner needs)
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Is there anything else you can tell me about your child that you think would help us support their learning?
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Does your learner have any Dietary restrictions ? We do not provide lunch, however there may be times we have parties and potlucks.
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Does you child have any food, medication, or environmental allergies? if so, what is the reaction? Is an EpiPen required?
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Does your child require any medication during the day? such as an Asthma inhaler, etc
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Is your child currently receiving care for any mental health or social/emotional challenges (such as ADHD, Anxiety, Autism, Depression, OCD, etc.)?if so, please share how we can best show up for your learner.
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Is your child being treated for a chronic health condition (such as Cerebral Palsy, Cystic Fibrosis, Diabetes, Multiple Sclerosis, etc.)? if so, please share how we can best show up for your learner.*Your answer
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Is there any additional information about your student you would like to provide?
Would you be able to provide a copy of your child's most recent immunization record? Per the Tennessee Department of Health guidelines, immunizations must be current for the 2024-2025 school year
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YES
NO
If No, Please Explain
Does your child have a preferred nickname they would like to be called ?
*
If there were an emergency who would you like for us to contact if we can not get a hold of you? Please list your contact data first then list 2 people others. Name, relation to the learner, Phone Number
*
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