parent Feedback Form Student Name Parent/Guardian Name Date Relation to Student * ChooseBiological ParentStep ParentAdoptive ParentFoster ParentGrandparentOther If other, please specify. Child's Hobbies Athletic Activities Clubs and Organizations Jobs and/or Chores Academic Performance - English Language Arts *ChooseAbove AverageAverageBelow AverageFailing Academic Performance - Social Studies *ChooseAbove AverageAverageBelow AverageFailing Academic Performance - Mathematics *ChooseAbove AverageAverageBelow AverageFailing Academic Performance - Science *ChooseAbove AverageAverageBelow AverageFailing Does your child receive special education, remedial services, or attend a special class/special school? *ChooseNoYes If yes, type of service, class, or school. Has your child repeated any grades? *ChooseNoYes If yes, grade(s) and reason(s) Has your child historically had any academic difficulties in school? *ChooseNoYes If yes, please describe the difficulties. Does your child have a medical diagnosis *ChooseNoYes If yes, please describe. Does your child have a social/emotional diagnosis? *ChooseNoYes If yes, please describe. Does your child have a diagnosed learning disability? *ChooseNoYes If yes, please describe. What concerns you most about your child? Please describe your child's strengths. Is your child prescribed any medication? *ChooseYesNo If yes, please describe. Does your child receive any private/outside therapies? *ChooseNoYes If yes, please describe. Any additional comments or concerns Submit
