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Kindergarten Readiness Checklist
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* Indicates required question
Email
*
Your email
Student’s Name:
*
Your answer
Students Birthdate: (M/D/Y)
*
MM
/
DD
/
YYYY
Completed by:
*
Your answer
Please indicate if your child is receiving services for any of the following:
*
Yes
No
Speech and Language delays
Impairment or physical disability
Significant developmental delays
Vision or Hearing impairment (circle one/both)
Severe behavioural difficulties
Medical concerns
Yes
No
Speech and Language delays
Impairment or physical disability
Significant developmental delays
Vision or Hearing impairment (circle one/both)
Severe behavioural difficulties
Medical concerns
Comments:
Your answer
It is recommended children receive these screens previous to beginning school. Has your child recently had a:
*
Yes
No
Vision test
Hearing test
Medical Check-up
Speech Language test
Yes
No
Vision test
Hearing test
Medical Check-up
Speech Language test
Comments:
Your answer
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