Name of Student
Name:
Date:
Student Information
Date of Birth:
Age:
Gender:
Mailing Address:
Postal Code:
Parent/Guardian:
Relationship to Student:
Contact Numbers:
(H)
(W)
(C)
Education Status
School: ________________________________________
Attending Regular School? Always Sometimes Never
Gets suspended? Always Sometimes Never
Highest Completed Grade Level __________
Grade currently enrolled __________
Has the student been socially promoted? Yes No
Have there been any educational assessments completed by the school? Yes No
Does the student have an ISSP or participant in a modified program? Yes No
Areas of interest:
Please describe any learning challenges: