Date Received______

Pioneer Family Academy

Questionnaire for Incoming Students3rd-12th Grade

Student’s Name: ______Parent’s Name______

Home #: ______Cell #: ______Work #:______

Date: ______Entering Grade: ______Age: ______Male [ ] Female [ ] Birth Date ______

1. How long have you been home schooling? ______Brieflydescribe your student’s academic history: Which grades in: Public ______Private ______Home ______

2. How does the student feel about coming into PFA and a classroom environment? ______

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3. Is it likely that the student will attend our school for the full year? If no, please explain______

______4. Health Status:Does the student have any physical, emotional, or behavioral problems we should be aware of? (Such as: asthma, seizures, diabetes, vision/hearing problems, etc.)

Please be specific: ______

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Is your child on any medication? ______If yes, please list the medication:______

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5. Is there anything we need to know that would be helpful in understanding this student? Include any stresses or circumstances we need to be aware of such as: (a new baby, a new job, new marriage, divorce, custody issues, illness in the family, mom works, dad travels, etc. ______6. Family dynamics: Birth Order, (example 1 of 4) ______7. Has the student ever been tested for or diagnosed with a learning disability (ADD, ADHD, autism, Asperger’s syndrome, dyslexia, processing disorders, etc.) or enrolled in any special school (i.e. speech or language, academic or reading resource, learning disability placement, etc.)? Please explain. A copy of the report is required. ______

8.Has your student had academic testing? ______Is this student at grade level in Math? ______

Does student read at grade level? ______Please explain: ______

Please attach current academic testing & latest report card.

Please write a brief appraisal of your student’s character qualities, and maturity level (both strengths and weaknesses.) ______

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9. Has your student ever been suspended or expelled from any program (sports, Sunday school, music lessons, etc.)______Does the student have a criminal record? ______

Please explain______

10. Describe special talents, areas of interest and activities of your student______

______

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11.Has your student made a commitment to Christ? Yes_____ No ____ When? ______Brief explanation ______

______Does he/she understand the plan of salvation?______

Below are questions to be answered by families coming into PFA for the first time.

Faith/Church affiliation: ______

Attendance: _____regular _____occasional _____seldom _____never

12. Why are you homeschooling? ______

______

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13. Briefly describe your family’s philosophy of education: ______

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14. Why would you like your son/daughter to attend PFA? ______

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15. Are you interested in being a room mom in this student’s class? Y/N______

To be answered by 3rd – 6th grade student: (7th – 12th use Student Questionnaire)

16. Describe why you would like to attend PFA: ______

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17. Describe any area of your character in which you would like to see growth and/or changes: ______

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Parent Signature ______Date______

PFA/Enr/Questionnaire 7-14-16