PLEASANTS COUNTY SCHOOLS PARENTREPORT

To assist in the educational evaluation of your child and as stated in Policy 2419, it is required that the parent/guardian provide written information about the child. Please complete the form and provide further information and explanation, if applicable, in the space provided.

Student Name ______Grade ______Date______

Address ______Phone ______School ______

Is child covered by Medicaid? _____ Yes _____ NoIf yes, Medicaid # ______

FamilyHistory: Father’s Name ______Mother’s Name ______

Siblings living in the home/ages: ______

Besides siblings, other’s living in the home/relationship to child: ______

Check any statement that is applicable to your child. Explain, when appropriate.

_____ / Situations at home that might affect school work or behavior (i.e. new baby, divorce, move, death)?
_____ / Unusual or difficult behavior problems? If yes, explain:
_____ / Problems with pregnancy/delivery/child’s first month? If yes, explain: / Pregnancy ______full term _____premature
Birth Weight ______
_____ / Respond normally to light, sound, and/or movement? If applicable, explain:
_____ / Medical diagnosis: / Prescribed Medication:
_____ / Other information that may be helpful in understanding your child?

Medical/DevelopmentalHistory: Please indicate any that apply to your child:

Coordination issues _____ / Ear infections _____ / Vision problems _____ / Wears glasses _____
Epilepsy/seizures _____ / Frequent colds _____ / Pneumonia _____ / Asthma/allergies _____
Chicken pox _____ / High fevers _____ / Problems with physical development _____
Circle areas of concern: sucking swallowing chewing choking drooling regurgitating fluid through the nose
Serious injury/accident/surgery/long term medical treatment _____ (explain if yes):
Age when child first: rolled over _____ crawled _____ walked alone _____ fed self _____ toilet trained _____

Social HistoryDoes your child join in group activities with: ___ siblings ___younger children ___ older children ___ plays alone

How does your child get along with other family members: ______

What are your child’s interests? ______

Indicate how frequently your child exhibits the following behaviors:O=often, S=sometimes, R=rarely, N=never

Nervousness _____ / Shyness _____ / Bed wetting _____ / Aggressiveness _____ / Sleep Difficulty _____
Thumb sucking _____ / Nail biting _____ / Temper tantrums _____ / Destructiveness _____ / Unusual fears _____

Speech and Language HistoryCheck all that apply:

Follows simple commands _____ / Understands things said to him/her _____ / Speaks in single words _____
Speaks in simple phrases _____ / Speaks in sentences _____ / Speaks fluently _____
Speaks but others don’t understand ____ / Has problems pronouncing words _____ / Listens to stories _____
Forgets names _____ / Uses gestures to express needs _____ / Forgets what he/she wants to say _____
Starts conversations _____ / Has a good attention span _____ / Needs to have things repeated _____
Age when child first: babbled/cooed _____ used meaningful words _____ put words together _____ used sentences _____

Describe any speech/language difficulties your child has (include when the problem was first noticed and by whom). Include information about any previous speech/language assessments or therapy you child has received:

______

ATTACH ANY ADDITIONAL INFORMATION YOU FEEL MAY HELP MEET YOUR CHILD’S EDUCATIONAL NEEDS. YOU MAY USE THE BACK OF THIS FORM FOR ADDITIONAL INFORMATION (ex. suggestions/concerns/comments).Please return to ______by ______(date) Rev. 08/12