Child’s Name: _____________________________________________

Contact Information: put a star * next to the best number to call

#1 Parent/Guardian Name: __________________________________

Cell/Home Phone: _______________ Work Phone: _______________

#2 Parent/Guardian Name: __________________________________

Cell/Home Phone: _______________ Work Phone: _______________

Emergency Contact: Name & Relationship _______________________

Phone Number: ____________________________________________

Please share an email address where I can send you newsletters.

_________________________________________________________

What languages are spoken at home? __________________________

_________________________________________________________

What goals do you have for your child this year? (social / academic)

_________________________________________________________

______________________________________________

_____________________________________________

______________________________________________
What areas are you most concerned about?

□ work habits at school □ work habits at home □ attentive listening

□ peer relationships □ self esteem □ respect for others
□ self-control □ skill level in _________________________
□ other ______________________

What are your child’s most favourite school activities? Least? _______

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How does your child feel about school? _________________________

_________________________________________________________

What are three words you would use to describe your child?

_________________________________________________________

Please list any holidays that you celebrate at home. _______________

_________________________________________________________

Please tell me anything else that you would like me to know about
your child, or anything that you feel would be useful for me to know
(e.g. recently moved homes, divorce/separation, new baby, etc).
_________________________________________________________

_________________________________________________________

__________________________________________

__________________________________________
Thank you so much for sharing! This information
will be kept confidential and will help me get a head
start on getting to know your child.