Student information form Copy

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Student Information Form

Child’s full name:*

Date of birth: *

Primary Language: *

Primary caregiver’s name: *

Relationship to child: *

Occupation: *

Contact number:*

E-mail address:*

Primary caregiver’s name: *

Relationship to child: *

Occupation: *

Contact number:*

E-mail address:*

Student’s address: *

Who referred you to The Gateway School of Mumbai?*

Child’s schooling

Current school: *

Attending since: *

Current grade: *

Previous School:

Dates attended:

Grade(s) completed:

Previous School:

Dates attended:

Grade(s) completed:

General Information:

At what age did your child *

a. Crawl:*

b. Walk:*

c. Babble:*

d. Say his/her first word:*

e. Speak in 2-3 words:*

f. Become toilet trained:*

How old was your child when you first suspected something unusual, and what appeared to be unusual? *

What are some of your child’s greatest strengths (i.e. what can the child do well with minimal to no support)? *

What does your child struggle with? What is challenging for your child? *

What has your child been diagnosed with? Please attach relevant reports.

a. How accurate do you believe the reports to be? If you believe the reports are inaccurate, please share why*

Information about your child’s current school:

Does your child currently receive any support services (i.e. one-on-one support, remedial, shadow teacher, therapies, etc.) within the school? If so, what support does your child receive at school? Please share why.*

Does your child currently receive any support services (i.e. tutoring, remedial, therapies, etc.) outside of school? If so, please specify which ones and share why.*

Has your child repeated a grade? If so, which grade and why was your child asked to repeat that grade?*

Has your child’s current school suggested that you exit and find another school? If yes, why? If not, then why are you thinking of leaving the school? *

Why do you think Gateway, specifically, will be an appropriate school for your child?*

Information about your child’s physical, emotional and social development:

Describe any physical or health problems your child has or has had.*

Is your child taking any medication? If so, please list and state why the child is taking each medicine. *

Have you visited a psychiatrist for support with your child? If so, what were the psychiatrist’s impressions. Please share a copy of the report.*

Is your child taking any medication? If so, please list and state why the child is taking each medicine. *

Is your child on any psychiatric medication? If so, please share details of the medication along with a copy of the prescription, and why they were prescribed.*

Does your child have friends of the same age? Is it a challenge for your child to make age-appropriate friends?*

What extracurricular activities or hobbies does your child enjoy?*

How would you describe your child’s self-esteem or self-confidence? *