Student Care Questionnaire

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Student Care Questionnaire

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Added: 12/21/2024

Student Care Questionnaire

For Students with Disabilities and Additional Needs

Student Info

First Name

First Name is required.

Last Name

Last Name is required.

Date of Birth

/ / Date of Birth cannot be a future date.

Age/Grade

Age/Grade is required.

Gender

M F

Gender is required.

Campus attending

Campus attending is required.

Plan to attend

Plan to attend is required.

Adult Info

Parent/Guardian#1

First Name

First Name is required.

Last Name

Last Name is required.

Relationship to Student

Relationship to Student is required.

Email address is not valid

Email is required.

Phone Number

Phone Number is required.

Phone Type

Cell Home

Phone Type is required.

Address

Parent/Guardian#2

First Name

Last Name

Relationship to Student

Email address is not valid

Phone Number

Phone Type

None Cell Home

Address

Care Info

Student's primary health concerns/diagnosis

Student's primary health concerns/diagnosis is required.

Medications we should be aware of

Type of assistance that you think would be the most beneficial for your student

Side-by-Side (One-on-one volunteer that assists in ways unique to your student's need) Room Assistant (Oversees multiple students in a room who could benefit from basic help with attention, redirection, sensory or social needs) Personal Care Assistant (Assistance provided by parent/guardian. A background check is required) No extra assistance is required. I just want you to be aware.

Type of assistance that you think would be the most beneficial for your student is required.

Vision

Vision is required.

Hearing

Hearing is required.

Uses

Speech

Speech is required.

Can understand what others say

Can understand what others say is required.

Allergies

Behavior

Shy Outgoing Plays alone Plays in groups Adapts to new situations well Adapts to new situations with difficulty Responds to correction well Responds to correction with difficulty Has difficulty sitting in a group Has difficulty attending Sometimes threatens others Sometimes hits, bites, or hurts self/others Is somewhat destructive Hyperactive and/or ADD Sometimes attempts to run away Has difficulty with transitions Has unpredictable vocalizations At times exhibits vocalizations or verbal outburstsBehavior is required.

This is most important to me

This is most important to me is required.

This is most important for me

This is most important for me is required.

This is How Best to Support Me

This is How Best to Support Me is required.

Additional concerns not already addressed

Submit

651.429.9227
7015 20th Ave S, Centerville, MN 55038