Upload
others
View
10
Download
0
Embed Size (px)
Citation preview
Waiting list
NAME OF CHILD: _____________________________________________________________________________________________________________________ DATE OF BIRTH : _______________________________________________________________ GENDER □ M □ F M / D / Y NAME OF SCHOOL/PRESCHOOL/DAYCARE TRANSFERRING FROM: __________________________________________________________________ REASON FOR TRANSFER: __________________________________________________________________________________________________________ DO YOU HAVE ANY CONCERNS ABOUT YOUR CHILD’S DEVELOPMENT? □ YES □ NO
□ Hearing □ Vision □ Language □ Gross Motor □ Fine Motor □ Social □ Autism □ Aspergers □ ADD □ ADHD □ Behavior Disorder □ Down syndrome □ Anxiety □ Obsessive Compulsive □ Selective Mutism □ Other _________________________________________________________________________________________________________________________ (SPECIFY) DOES YOUR CHILD HAVE ANY DEVELOPMENTAL DELAYS ? □ Yes □ No ___________________________________ DOES YOUR CHILD HAVE ANY PHYSICAL PROBLEMS ? □ Yes □ No ________________________________________ NAME OF FATHER: _________________________________________________________________________________________________________________ OCCUPATION FATHER: _____________________________________________________________________________________________________________ PHONE # HM: _________________________________________________ WK: ______________________________________________________________
CELL: ________________________________________________ EMail Address: ___________________________________________________________________________________________________________________ NAME OF MOTHER: _________________________________________________________________________________________________________________ OCCUPATION OF MOTHER: __________________________________________________________________________________________________________ PHONE # HM: __________________________________________________ WK: ______________________________________________________________
CELL: _______________________________________________ EMail Address: ____________________________________________________________________________________________________________________ Date: ________________________________________ Signature: _____________________________________________________________________
FOR OFFICIAL USE ONLY SCHOOL YEAR: CLASS: _______________________________ __________________________________ _______________________________ ____________________________________ Children transferring in classes Infant II to Standard VI must attach copies of recent and previous year’s Report Cards.