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Parent Input Form

PARENT INPUT

The information requested will greatly assist the staff in the evaluation of your child. If you have additional information that you want the staff to consider (and that is not requested here) please feel free to attach additional pages. Please disregard any question that makes you uncomfortable. If you would prefer to provide this information by phone, please contact Bluntzer, Maggie at (361) 384-0276.

Student Name*

Answer required for "Student Name"

Student Age*

Answer required for "Student Age"

Student Date of Birth*

Answer required for "Student Date of Birth"

Gender*

Answer required for "Gender"

School Year*

Answer required for "School Year"

Campus*

Answer required for "Campus"

Grade*

Answer required for "Grade"

GENERAL INFORMATION

Mother's Name:*

Answer required for "Mother's Name:"

Occupation:*

Answer required for "Occupation:"

Level of Education:*

Answer required for "Level of Education:"

Father's Name:*

Answer required for "Father's Name:"

Occupation:*

Answer required for "Occupation:"

Level of Education:*

Answer required for "Level of Education:"

With whom does your child live?

Answer required for "With whom does your child live?"

Relationship to child:

Answer required for "Relationship to child:"

Other children in the home: (Name, Age & Relationship)

Answer required for "Other children in the home: (Name, Age & Relationship)"

Other adults in your child's home: (Name & Relationship)

Answer required for "Other adults in your child's home: (Name & Relationship)"

Do any family members have learning problems? If yes, please explain.

Answer required for "Do any family members have learning problems? If yes, please explain."

Compared to other children in the family, this child's development was:

Answer required for "Compared to other children in the family, this child's development was:"

At what age, in months, was your child able to do the following?

Sit without support:

Answer required for "Sit without support:"

Crawl:

Answer required for "Crawl:"

Walk without support:

Answer required for "Walk without support:"

Use spoon fairly well:

Answer required for "Use spoon fairly well:"

First word:

Answer required for "First word:"

Reasonably well toilet trained:

Answer required for "Reasonably well toilet trained:"

YOUR CHILD'S FRIENDS & ACTIVITIES

Does your child prefer to play/socialize with:

Answer required for "Does your child prefer to play/socialize with:"

Does your child have friends his/her own age?

Answer required for "Does your child have friends his/her own age?"

Does your child have friends who are younger?

Answer required for "Does your child have friends who are younger?"

Does your child have friends who are older?

Answer required for "Does your child have friends who are older?"

YOUR CHILD AT HOME

Does your child have the following items at home?

Computer

Answer required for "Computer"

Books

Answer required for "Books"

Tape recorder

Answer required for "Tape recorder"

CD Player

Answer required for "CD Player"

Video Games

Answer required for "Video Games"

Television

Answer required for "Television"

Education toys

Answer required for "Education toys"

Radio

Answer required for "Radio"

What kinds of activities does your family do together? (Read, play games, camp, etc.)

Answer required for "What kinds of activities does your family do together? (Read, play games, camp, etc.)"

Have there been any important changes within the family during the last three years? (For example, changes, moves, births, deaths, serious illnesses, separations, divorce)

Answer required for "Have there been any important changes within the family during the last three years? (For example, changes, moves, births, deaths, serious illnesses, separations, divorce)"

With whom in the family is your child particularly close?

Answer required for "With whom in the family is your child particularly close?"

Has your child ever been separated from the family due to family problem, health reasons, etc.? If yes, please explain.

Answer required for "Has your child ever been separated from the family due to family problem, health reasons, etc.? If yes, please explain."

How did your child react to the separation?

Answer required for "How did your child react to the separation?"

Describe your child's behavior at home with peers, siblings, neighbors, and parents. (For example, is your child generally well-behaved? Social? Affectionate? Withdrawn?)

Answer required for "Describe your child's behavior at home with peers, siblings, neighbors, and parents. (For example, is your child generally well-behaved? Social? Affectionate? Withdrawn?)"

What methods of discipline are used with your child at home? (For example, spanking, extra chores, early bedtimes, taking away of privileges; is he given rewards for good behavior?)

Answer required for "What methods of discipline are used with your child at home? (For example, spanking, extra chores, early bedtimes, taking away of privileges; is he given rewards for good behavior?)"

How does your child react to discipline?

Answer required for "How does your child react to discipline?"

Who usually disciplines Jesus at home?

Answer required for "Who usually disciplines Jesus at home?"

The primary language in the home is:

Answer required for "The primary language in the home is:"

How long has your child lived in the United States?

Answer required for "How long has your child lived in the United States?"

What time does your child go to bed at night?

Answer required for "What time does your child go to bed at night?"

Does your child eat breakfast?

Answer required for "Does your child eat breakfast?"

What does your child do when not in school? (Please list your child's common indoor and outdoor activities.)

Answer required for "What does your child do when not in school? (Please list your child's common indoor and outdoor activities.)"

Does your child have a part-time job after school or on weekends?

Answer required for "Does your child have a part-time job after school or on weekends?"

If yes, please provide the average number of hours worked per week.

Answer required for "If yes, please provide the average number of hours worked per week."

YOUR CHILD AT SCHOOL

Has your child talked to you about difficulties or problems at school? Please explain.

Answer required for "Has your child talked to you about difficulties or problems at school? Please explain."

Do you think your child is having difficulties in school?

Answer required for "Do you think your child is having difficulties in school?"

If you think your child is having difficulties, please explain your concerns.

Answer required for "If you think your child is having difficulties, please explain your concerns."

What do you think is causing Jesus's difficulties at school?

Answer required for "What do you think is causing Jesus's difficulties at school?"

When did you first notice the difficulties?

Answer required for "When did you first notice the difficulties?"

If you have discussed these concerns with the school, please indicate when and with whom you shared your concerns.

Answer required for "If you have discussed these concerns with the school, please indicate when and with whom you shared your concerns."

If your child qualifies, what services or accommodations do you think are necessary so that your child can participate and benefit from school?

Answer required for "If your child qualifies, what services or accommodations do you think are necessary so that your child can participate and benefit from school?"

CHILDHOOD & MEDICAL HISTORY

Has your child ever had the following?

Answer required for "Has your child ever had the following?"

Never

Yes

Frequent fevers

Never

Yes

Frequent earaches

Never

Yes

Frequent vomiting

Never

Yes

Thumbsucking

Never

Yes

Nightmares

Never

Yes

Sleepwalking

Never

Yes

Head banging

Never

Yes

Rocking of body

Never

Yes

Teeth grinding

Never

Yes

Bedwetting

Never

Yes

Fingernail biting

Never

Yes

Temper tantrums

Never

Yes

Run away from home

Never

Yes

Lost consciousness

Never

Yes

Convulsions

Never

Yes

If you answered yes to any, please list the age your child began and ended each behavior.

Answer required for "If you answered yes to any, please list the age your child began and ended each behavior."

CURRENT MEDICAL TREATMENT & MEDICATION

Doctor's reports, letters and diagnoses can be very helpful in completing this evaluation. Please attach Jesus's medical records so that the Committee can have a more complete picture of Jesus. If you would prefer, you may give the District written consent to seek those records from your doctors directly. Please notify at ( ) - to get the necessary form.

Please identify any medical problem for which your child is currently receiving medical care:

Answer required for "Please identify any medical problem for which your child is currently receiving medical care:"

Does your child appear to have any other physical health problems for which your child is not currently receiving medical care?

Answer required for "Does your child appear to have any other physical health problems for which your child is not currently receiving medical care?"

Please list all medications currently taken by your child (over the counter and prescription).

Answer required for "Please list all medications currently taken by your child (over the counter and prescription)."

Please describe any side effects your child experiences from these medications.

Answer required for "Please describe any side effects your child experiences from these medications."

Please identify any medication(s) taken by your child for over 1 year:

Answer required for "Please identify any medication(s) taken by your child for over 1 year:"

Please describe any hospital stays by your child, including the date, reason for the stay, the duration, and the result of treatment:

Answer required for "Please describe any hospital stays by your child, including the date, reason for the stay, the duration, and the result of treatment:"

What precautions do you take at home, in the community, on vacation or when your student is with friends or others to address his/her medical condition or illness?

Answer required for "What precautions do you take at home, in the community, on vacation or when your student is with friends or others to address his/her medical condition or illness?"

Does your child have a medical condition or illness with symptoms that are sometimes more serious than other times?

Answer required for "Does your child have a medical condition or illness with symptoms that are sometimes more serious than other times?"

If yes, please answer the following questions:

What is the name of the condition or illness?

Answer required for "What is the name of the condition or illness?"

When and how often is the condition or illness a problem for your child?

Answer required for "When and how often is the condition or illness a problem for your child?"

How does the condition or illness affect your child when the symptoms are most serious? (Are there things that he/she cannot do or things that are more difficult because of the condition or illness?)

Answer required for "How does the condition or illness affect your child when the symptoms are most serious? (Are there things that he/she cannot do or things that are more difficult because of the condition or illness?)"

Did your child used to have a serious medical condition or illness that has gone away?

Answer required for "Did your child used to have a serious medical condition or illness that has gone away?"

If yes, please answer the following questions:

What is the name of the condition or illness that your child used to have?

Answer required for "What is the name of the condition or illness that your child used to have?"

When and how often is the condition or illness a problem for your child?

Answer required for "When and how often is the condition or illness a problem for your child?"

How did the condition or illness affect your child when the symptoms were most serious? (Were there things that he/she could not do or things that were more difficult because of the condition or illness?)

Answer required for "How did the condition or illness affect your child when the symptoms were most serious? (Were there things that he/she could not do or things that were more difficult because of the condition or illness?)"

Is the condition or illness likely to return?

Answer required for "Is the condition or illness likely to return?"

Is there any other information about your child or family that you would like the district to consider when evaluating your child for eligibility? If so, please provide it here.

Answer required for "Is there any other information about your child or family that you would like the district to consider when evaluating your child for eligibility? If so, please provide it here."

Signature of Parent/Guardian/Adult Student:*

Signature Required

Name: Date:

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Signature *

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Full Name *

Date:

Signature Date*

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Signature of Person Assisting (if any) & Staff Position:

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Signature Date

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Attach any documents or information.

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Confirmation Email

Confirmation Email *

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