Information Record

Student Information Record

STUDENT:

Name______________________________________________________________

Date of Birth________________________________________________________ 

School ____________________________________________________________

Grade_____________

LEGAL GUARDIANS:

Legal Guardian #1
 

Name______________________________________________________________

Name______________________________
Phone______________________________
Relationship_________________________
 

Name______________________________
Phone______________________________
Relationship_________________________

Child’s Doctor__________________________ Phone_______________________________

Child’s Dentist__________________________ Phone_______________________________

Please list and explain any medical, physical, behavioral, or psychological conditions: ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________

Please list any medications that your child is currently taking:

______________________________________________________________________________________________________________________________________

ACADEMIC INFORMATION

Please list academic areas in which your child has difficulty:

______________________________________________________________________________________________________________________________________

Please list any diagnosed learning needs:

______________________________________________________________________________________________________________________________________

Please list any special services, accommodations and/or modifications your child receives at school:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How does your child work best at home?

___________________________________________________________________

___________________________________________________________________

Please list any other information that you believe will be helpful for me to know when working with your child:

_________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________

Parent/Guardian Signature_____________________________________________

Date_______________________________________________________________

How did you hear about Catron Community Learning Center?

___School
___The New Mexican ___Kids Summer ___New Mexico Kids

___Tumbleweeds ___Yellow Pages ___Friend or Relative ___Internet Search

___Church
___Other ___________________________________________