St. Joseph Information Form for Child with Special Needs or Medical Conditions: 2021-2022
Help us provide a more effective experience for your child
Child's First Name
*
Child's Last Name
*
Child's Date of Birth
*
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Month
-
Day
Year
Family's Main Phone (Home)
*
Family's Main Phone (Cell)
*
Family's Email Address
*
Child's Grade for School Year 2021-2022
*
Please Select
1
2
3
4
5
6
7
8
Please check your child’s condition:
IEP
Self-contained classroom
Mainstreamed
Other
Classification of Special Needs:
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Developmental Delay
Emotional Problem
Blind/Hearing Impaired
Neurologically Impaired
Autism
Gluten and/or Celiac
Epi-pen
Allergies (please specify below)
Learning Disabled (please specify below)
Dyslexia
Attention Deficit
Memory/Thinking Disorder
Perceptual/Motor Impairment
Hyperactivity
Visual/Auditory
Coordination Deficit
Impulsivity
ODD
PDD
Other
Allergies (if applicable)
Learning Disabilities (if applicable)
Medical Information (medication, seizures, diabetes, asthma, epi pen, etc.)
Other Information which will be helpful for the catechist to know:
Parent's First Name
*
Parent's Last Name
*
Parental Signature:
*
Please verify that you are a human & not a robot.
*
Submit
Should be Empty: