Student Care Questionnaire

Work Entry

Added: 12/3/2023

Student Care Questionnaire

For Students with Disabilities and Additional Needs

Student Info

First Name

Last Name

Date of Birth

/ /

Age/Grade

Gender

M F

Campus attending

Plan to attend

Adult Info

Parent/Guardian#1

First Name

Last Name

Relationship to Student

Phone Number

Phone Type

Cell Home

Address

Parent/Guardian#2

First Name

Last Name

Relationship to Student

Phone Number

Phone Type

None Cell Home

Address

Care Info

Student's primary health concerns/diagnosis

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.

Vision

Hearing

Uses

Speech

Can understand what others say

Allergies

This is most important to me

This is most important for me

This is How Best to Support Me

Additional concerns not already addressed

Submit