questionnaire

name of parent or guardian *

First Name

Last Name

child's name *

First Name

Last Name

child's needs *

please check any applicable information from the list below that might be helpful for volunteers to best minister to your child:

short attention span / easily distracted

temper tantrums

challenges with transitions

aggressive behavior

challenges with changes in routine

shyness

challenges with following directions

challenges with fine motor skills (cutting, pasting, etc.)

issues with light and/or sounds

difficulty completing activities

needs visual presentations

unable to read

trouble sitting in a group

issues with separation anxiety

tends to be possessive

tends to run (leaves classroom without permission, wanders, etc.)