STUDENT INFORMATION FORM

SCHOOL HISTORY

Previous schools attended (list last school first)

Has student been in any special program?

If Yes, specify

If student’s records from previous schools not available, please give full name and address of last school where records can be obtained.

FAMILY HISTORY

PARENTS

SIBLINGS (brothers and sisters)

Additional information on family relationships

LANGUAGES

HEALTH HISTORY

Does your child have any health condition(s) that school personnel should know about?

If Yes, explain

Immunizations (record dates of initial childhood and last immunization):

Development:

Were there any complications in the pre-natal, delivery, or post-natal periods?

If Yes, explane

Are there any present or past sleeping or eating problems?

If Yes, explane

Please check the following items where appropriate and give date of occurrence