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