Child Participation + Personal Goals
Thanks for your interest in our Robot Program!
We're committed to making sure every child gets the most out of their experience. For each participating child, please answer the following questions to the best of your knowledge. Each child will have their own form.
Email address *
What is your child's first name or nickname? *
Your answer
What the best way to contact the parent? *
Please include preferred contact information, email or phone number.
Your answer
How old is your child? *
Your answer
Does your child live with siblings? *
What grade is your child in? *
Your answer
What type of classroom is your child in? *
How would you describe your child's verbal abilities? *
In which of the following areas do you feel your child could benefit from additional help/practice? Please check all that apply. *
Required
If you chose Social Skills, please check off all skills that your child would benefit from additional help/practice in.
If you chose Communication Skills, please check off all skills that your child would benefit from additional help/practice in.
If you chose Emotional Skills, please check off all skills that your child would benefit from additional help/practice in.
If you chose Cognitive, please check off all skills that your child would benefit from additional help/practice in.
If you chose Activities of Daily Living, please check off all skills that your child would benefit from additional help/practice in.
Please list any other information about your child that you feel is important for us to know.
Your answer
Are there any specific goals, not mentioned here, that you would like your child to work on with the robot?
Your answer
Which activities are you interested in?
What is your home ZIP code? *
Your answer
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Embodied Inc.. Report Abuse - Terms of Service - Additional Terms