parent Feedback Form Student Name Parent/Guardian Name Relation to Student * Choose Biological Parent Step Parent Adoptive Parent Foster Parent Grandparent Other If other, please specify. Child's Hobbies Athletic Activities Clubs and Organizations Jobs and/or Chores Academic Performance - English Language Arts *Choose Above Average Average Below Average Failing Academic Performance - Social Studies *Choose Above Average Average Below Average Failing Academic Performance - Mathematics *Choose Above Average Average Below Average Failing Academic Performance - Science *Choose Above Average Average Below Average Failing Does your child receive special education, remedial services, or attend a special class/special school? *Choose No Yes If yes, type of service, class, or school. Has your child repeated any grades? *Choose No Yes If yes, grade(s) and reason(s) Has your child historically had any academic difficulties in school? *Choose No Yes If yes, please describe the difficulties. Does your child have a medical diagnosis *Choose No Yes If yes, please describe. Does your child have a social/emotional diagnosis? *Choose No Yes If yes, please describe. Does your child have a diagnosed learning disability? *Choose No Yes If yes, please describe. What concerns you most about your child? Please describe your child's strengths. Is your child prescribed any medication? *Choose Yes No If yes, please describe. Does your child receive any private/outside therapies? *Choose No Yes If yes, please describe. Any additional comments or concerns Submit