| Questionnaire for Parents of Children with Special Needs |
Child’s age _________ Parent’s Pager #_________________ List any special needs your child has _________________ Class _____________ Where will you be while your child is in this class? _________________ Can your child be included with other children in class? ________________ Check any applicable information that might be helpful for volunteers to best minister to your child. _____ Short attention span/easily distracted _____ Allergies Please list: ___________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ _____ Temper tantrums _____ Problems with transitions _____ Aggressive behavior _____ Problems with changes in routine _____ Shyness _____ Problems following directions _____ Problems with fine motor (cutting, pasting) _____ Special bathroom needs Please explain: ________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ _____ Difficulty completing activities _____ Needs visual presentations _____ Can’t read _____ Trouble sitting in a group _____ Issues with separation anxiety _____ Tends to run (leaves classroom without permission; wanders) _____ Tends to be possessive Helpful special suggestions about your child (for example, “don’t allow arguments between my child and another child to escalate.”) ________________________________________________________________________ ________________________________________________________________________ Do you want to be notified if there’s a problem with your child? Yes_____ No_____ |