____________________, _______________________________________________

Family  Name                          Student First Name(s)

 

 

 

____________________________________________

                                                E-mail / phone

 

                                               

                                                ___________________________________________

                                                Your Name

 

 

 

 

Please provide any information that pertains to your child.  This will help me provide the best methods to instruct them and/or ensure their safety.

 

Does your child suffer from any of the following conditions:

 

 known allergies? (if yes, list) _______________________________________________

 

color blindness?                      _______________________________________________

 

skin sensitivity?                       _______________________________________________

 

wear contact lenses?               _______________________________________________

 

Are there any considerations I should be aware of related to your child’s learning?

 

Academic difficulty (without IEP)    ___________________________________

 

Squeamishness                                    ___________________________________

 

Other concerns                                    ___________________________________

                                                                                   

                                                            ___________________________________