NAME:______________________________ AGE:_____________________ BIRTHDAY:__________________

ADDRESS:_______________________________________________ E-MAIL:____________________________
MOMS PHONE #:_____________________________ DADS PHONE #:_____________________________
MOMS WORK LOCATION & PHONE NUMBER:_________________________________________________
DADS WORK LOCATION & PHONE NUMBER:__________________________________________________
TRANSPORATION INFORMATION: (circle one for each)
TO SCHOOL:

car

walk

bus#:_______________ other: ________________________

FROM SCHOOL:

car

walk

bus#:_______________ other:_________________________

Who lives at home with your child? (i.e. one or both parents, siblings, grandparents, nanny):
___________________________________________________________________________________________
___________________________________________________________________________________________
Does your child have any health concerns? If yes, please list them below

___________________________________________________________________________________________
___________________________________________________________________________________________
In your opinion, what are your childs strengths? (academic and non-academic)
___________________________________________________________________________________________
___________________________________________________________________________________________
In your opinion, what areas does your child need to improve in? (academic and nonacademic)
___________________________________________________________________________________________
___________________________________________________________________________________________
Please use the space below (and the back of this paper) to tell me any other information that
you would like for me to know. (interests outside of school, sports, etc)
___________________________________________________________________________________________
___________________________________________________________________________________________