KidZone Club - Flood Survivors Support Group for Kids
Please complete form to be considered for our group. Students ages 7 -11.
Email address *
Name of Parent(s) *
Your answer
Best phone to reach you *
Your answer
Name of Child and Date of Birth *
Your answer
Where does the child currently attend school? *
Your answer
Has the child had any academic or behavioral problems in school? *
If yes, check all that apply:
Are behavioral problems present in situations other than school (Home/Other places)? *
If yes, check all that apply:
Does the child have any medical problems? *
If yes, please describe...
Your answer
Is the child under the care of a mental health professional? *
If yes, please provide the professional's information...
Your answer
Has the child been diagnosed with any learning disabilities? *
If yes, please describe...
Your answer
Does the child have any history of depression, anxiety or other similar problems? *
If yes, please describe...
Your answer
Is there a history of abuse (sexual, physical, etc.) towards the child? *
If yes, please describe...
Your answer
Who is responsible for bringing the child to group? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms