Exit Summary- Parent Input Form

Child’s Name __________________________________________        Date of form completion _______________

Parent/Guardian completing the form ______________________________________

Please complete the following questions to the best of your ability. Not all of the sections or choices in this survey may be directly relevant to your child, but please complete those sections and choices that best reflect your concerns and thoughts about adult life for your child. Completing this survey will help teachers, VR counselors, and adult service staff to better understand you and your child’s expectations for the future. It will provide vital information that can lead to successful transition planning.

Educational Information/Concerns:

  1. How old is your son/daughter now? _____________

  1. At what age do you anticipate or plan for your child to graduate high school?

_____        age 17                _____        age 18                _____        age 19                _____        age 20                

_____        age 21                _____        uncertain

  1. What do you feel is your child’s strongest subject? ________________________________________
  2. What do you feel is your child’s weakest subject?   ________________________________________
  3. In what area(s) do you feel your child has the greatest need(s)? Please check all that apply. Of those needs checked below, please rank the top 5 areas of concern. (1= most important, 5=least important) 

If a concern is NOT state below, please comment below.

Additional Comments:

Future Education: 

  1. What do you anticipate for your son/daughter after graduation?

Please comment if you have chosen one of the first 5 options listed above.

  1. Has your son/daughter applied to a college/vocational school/adult classes at this point?  __________
  1. If so, has a final decision been made on where they will be attending/working after high school.

Career & Employment:

  1. I think my son/daughter will work in:

  1. What type of work does your son/daughter state he/she is interested in? __________________________

____________________________________________________________________________________

  1. Do you feel this is a realistic goal?         _____        Yes                _____        No

  1. What type of employment do you think he/she would enjoy? ___________________________________

____________________________________________________________________________________

  1. What type of support or assistance do you think your son/daughter will need in finding and maintaining a job? (Please check all that apply.)

Future Living:

  1. Five years after high school, where do you want your son/daughter to live

  1. What, if any concerns do you have about your son/daughter living on his/her own?

Transportation:

  1. Do you think your son/daughter will get a drivers license?         _____        Yes                _____        No

  1. After graduation, will your son/daughter travel around town by:

Recreation & Leisure:

  1. When my son/daughter graduates, I hope he/she will be involved in:

Adult Services:

  1. Please check the following services you are aware of.
  2. Please indicate which of the following services you have contacted or had contacted within the past.
  3. Finally, please indicate the services you would like more information on.

Services

Aware of

Contacted

More info.

  1. Vocational Rehabilitation

  1. Job Training Partnerships

  1. Job Services

  1. Vocational Rehabilitation Centers

  1. Social Security Administration

  1. Social and Rehabilitation Services

  1. Centers for Independent Living

  1. Respite Care

  1. Home and Community-based Services

  1. Food Stamps

  1. Other __________________________

Thank you for taking the time to complete the questionnaire. Please feel free to add any additional information/comments you feel relevant to help better prepare your child for life after high school.

Additional Comments: 

Parent/Guardian Signature: _________________________________________        Date ___________________