Student/Parent Questionnaire


Dear Parents/Guardians,
 
        The first day of school is almost upon us! To gain a little more knowledge about your child, I have created this questionnaire sheet for you to complete together.
       
        Thank you in advance for all of the support this upcoming school year. Please feel free to contact me by writing a note in your child’s communication notebook or calling me directly at the junior high or by emailing me – anovitske@fulton.cnyric.org.

 Student/Parent Questionnaire:
 
Student Name: _______________________________________________
 
Birthdate: ___________________________________________________
 
Address: ____________________________________________________
 
Phone Number: _______________________________________
 
Parent/Guardian Names: _____________________________________
 
Siblings: _________________________________________________
 
Favorites:
 
          Color: __________________________
 
        Animal: _________________________
 
        Activity: ___________________________
 
        Food: ___________________________
 
        Class subject: _______________________
  
Least Favorite:
 
        Color: __________________________
 
        Animal: _________________________
 
        Activity: ___________________________
 
        Food: ___________________________
 
        Class subject: _______________________
 
 
Medical Info:
 
Allergies: _______________________________________________ 
 
Current Medications and for what purpose: ____________________________________________________________
 
Does your child have Medicaid services and if so, who is their Medicaid Service Coordinator: _________________
 
Are you currently affiliated with any agencies (ex. Arise, Parents of Special Children, OCO) and if so, who is your contact: ________________________________
 
Any Additional Information ___________________________________________________________________________
 (Can include anything special about your child, other things they may like or dislike, or strategies that work for them):