Chancy and Bruce Educational Resources, Inc

CHANCY AND BRUCE

EDUCATIONAL

RESOURCES, INC.

Profile for Students 2nd-8th Grade

Date of Screening: Place: ST. FRANCIS OF ASSISI

Form Due Date: Assessment Time :

Chancy and Bruce Educational Resources, Inc. and St. Francis of Assisi Catholic School Have My Permission to Administer a Developmental Profile with my Child.

Parents, please complete the section below as well as the Parent Column on the reverse side titled “Students Behavior”, before forwarding to your school’s administration This form must be returned to St. Francis School in the attached self-addressed/stamped envelope by the due date indicated above.

Student’s Name______

Address______City______Zip______

Phone No. Home (______) ______Work (______) ______

DOB:______

Were there pregnancy or birth complications?______

Was this student premature or post term?______

Has this student had a history of chronic illnesses?______

Does this student experience allergies?______

Has this student had any unsettling experiences?______

What is the primary language spoken in this student’s home?______

______

Parent’s SignatureDate

We have applied for admission into the grade at St. Francis of Assisi Catholic School for the academic year .

Your help is requested in supplying as much of the information below as possible.

FOR PARENTS AND TEACHERS: Write U for USUALLY, S for SOMETIMES, R for RARELY on the line next to each behavior.

STUDENT’S BEHAVIOR: PARENT TEACHER

Puts forth resonable effort in the classroom______

Is respectful of peers and authority______

Gets along well with others______

Takes part in group actvities______

Approaches situations with confidence______

Participates with others in large groups______

Behaves positively with peers/classmates______

Works well independently______

Completes assigned tasks on time______

Pays attention______

Follows a sequence of directions______

Functions well in the classroom______

Is eager to learn new tasks______

Verbal communicaton is clear ______

Feels good about self______

Overreacts to situations______

Accepts responsibility______

Impulsive (acts or talks without thinking)______

Extremely overactive______

Oppositional in behavior with peers/authority figure______

TO: PRINCIPAL, TEACHER, OR COUNSELOR

School Currently Attending:______

Address:______

City/State/Zip:______Phone:______

Length of time in this school:

Does the student have a satisfactory attendance record?

Days Absent:Days Tardy:

Please describe any disabilities (physical, emotional, mental, language barriers, family situations) that affect this child’s progress:

Age Maturity Level: Early Average Advanced

ReadingSeries and grade level:

MathSeries and grade level:

PhonicsSeries and grade level:

If the child is not on grade level, please explain:

______

Do you feel that the child needs individual tutoring in reading? Yes No In math? Yes No

ClassroomConduct: Discipline & self-control: please comment:

Please comment on behavior/attitude, work/study habits, respect for authority, and peer relationships:

______

Has the child ever been recommended for further evaluation; i.e., for either academic, learning, behavioral, or attention problems? Yes No

If yes, did the parents follow through with this recommendation? Yes No

If no, what reason was given?

Has the child ever been a recipient of a Special Services Program, i.e., a Learning Disability Resource Center, a Developmental Reading, English, or Math Program, or a Behavioral Disorder Program?

______

Parent attitude toward school and degree of involvement – please comment:

Signature of Current School Administration Completing this Report Title

Telephone Date