Children with Exceptionalities Form

Parent/Guardian's Name *

Phone Number *

Email Address

Child's Name *

Child's Birth Date *

1. Tell us about your child’s personality. *

2. Tell us about your child’s exceptionality (extent of disability, allergies, physical limits, stamina, medical needs including medications, etc.). *

3. What are your child’s strengths? What does he/she enjoy doing for fun / what are his/her interests? *

4. What are your child’s dislikes? Any activities he/she dislikes, or things that are a cause of stress for him/her? *

5. Describe how your child has been best supported previously? Does your child have a support worker? What is their role? *

6. How does your child follow direction? Does your child have a tendency to wander away / run away from their group? *

7. How does your child get along with other children? How does your child get along with other adults / leaders / teachers? *

8. What program is your child registered for, or that you are planning to register your child for? *

9. Please tell us about any significant life events that we should be aware of that may have an impact on your child’s participation or their behavior (recent loss of a family member, friend or pet, divorce, move, etc.) *

10. Is there anything else you would like us to know about your child or information / resources about your child’s particular condition that you would like us to be aware of? Please describe: *