Parent/Guardian Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please let us know about your child's strengths and areas of concern by completing the form below.

To register for the Rowan University Reading Clinic, please use the link below:

https://forms.gle/uEYxr5ngQjWFoQwL7

If you have questions, please email odonoghue@rowan.edu.

Client first and last name:

Name of Parent(s)/Guardian(s)

Email Address

Address

Greatest concerns about your child's reading:

List three positive things about your child:

Child lives with:

Mother

Father

Both

Other:

Clear selection

How often has the family moved during student's life?

How old was he/she at the time?

Any siblings? If so, how old are they?

Any other persons live in home?

To which racial or ethnic group do you most closely identify?

African-American

Latino or Hispanic

Asian/Pacific Islander

Native American or Aleutian

Caucasian (Non-Hispanic)

Clear selection

Is any language other than English spoken at home?

List childhood diseases and serious injuries. Include ages at which they occurred:

Present height and weight:

Has your child ever had any unusual spells, seizures, nervousness, anxiety? If so, explain:

Has your child worn glasses?

Yes

Clear selection

If yes, when did your child begin to wear them?

What is the nature of the visual defect?

Have any hearing defects ever been reported?

Yes

Clear selection

Does the child have a history of ear infections?

Yes

Clear selection

If your child does have a history of ear infections, at what age did they begin?

When did they cease to be a problem?

How were the ear infections treated?

Date of last physical exam

YYYY

Does your child have any physical disabilities? _________ If so, describe:

Is your child taking any medication on a regular basis?________ If so, name the medication and describe the purpose:

Did the child attend kindergarten?

Yes

Clear selection

Age at entrance into first grade:

Has the child had any extended absences from school?

Yes

Clear selection

If so, when and for what reason?

Has the child changed school frequently?

Yes

Clear selection

If so, in what grades and for what reason?

Has the child repeated any grade?

Yes

Clear selection

If so, which ones and for what reason did he/she repeat?

When was the child's difficulty first noticed?

Has the child received any help for this difficulty?

In what school subjects does the child receive the best grades?

In what school subjects does the child struggle?

Describe any testings that your child has had:

What hobbies, clubs, activities does your child enjoy?

Does your child choose to read at home?

Yes

Sometimes

Clear selection

What is the average time your child watches TV each day?

Is there any other information you feel would be helpful for us to know?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Rowan University. Report Abuse

Forms