Student Name
Student Birthday
Address
Your child currently goes to: SchoolWorkNo activities
How does your get to school or work? BusCarBicycleWalking
What hours are they in school or at work? Morning (7AM-12PM)Afternoon (12PM-5PM)Evening (5PM-8PM)Night (8PM – 11PM)Other
Can your child speak, write and read English? AdvancedIntermediateBeginner
What is your child’s native language?
Can your child speak, write and read your native language? AdvancedIntermediateBeginner
Who works in your family?
How many children live in your home?
Does your child work best in groups or individually? In groupsIndividually
What activities does your child like? ArtMusicSportsDance
What type of personality does your child have? CalmEnergeticAggressiveShy
Does your child currently have any physical difficulties? Cannot seeCannot hearCannot speakCannot walkCannot use hands
Does your child currently have any learning difficulties? Trouble concentratingTrouble memorizingDoes not know how to
Does your child currently have trouble with? Being sadBeing nervousBeing scared
Is your child eating 3 meals a day? If so, what do they eat?
Is there any additional information about your child that you would like RISE Programs to know?
