Working Together for Success!

Success is my number one goal for my students! In order for me to meet the individual
needs of your child, I am asking that you share with me a bit of information about your
child and family. I truly appreciate this.
Students Name: ________________________________

Nickname:_____________________

Please list all the adults living in your childs household:

Name:
___________________________
___________________________
___________________________
___________________________

Relationship:
___________________________
___________________________
___________________________
___________________________

Please list all the children living in your childs household:

Name:
___________________________
___________________________
___________________________
___________________________
___________________________

Age:
_____
_____
_____
_____
_____

Relationship:
_________________________
_________________________
_________________________
_________________________
_________________________

1.

Describe your childs feelings about school.

2.

What are your childs strengths in and out of school?

3.

Does your child have any difficulties or problems with learning?

4.

What motivates your child?

5.

How would you rate your childs study habits? Circle one.
(excellent) 10 9 8 7 6 5 4 3 2 1 (needs a lot of work)

Comments:
6.

How organized is your child? Circle one.

(extremely organized) 10 9 8 7 6 5 4 3 2 1 (needs a lot of
work)
Comments:

7.

How does your child relate to other students socially?

8.

Are there any personal or physical problems I should be aware of?

9.

How much time do you expect your child to spend on homework each night?

10.

What can I do to ensure your child is a successful learner?

11.

Is there anything else youd like to share with me?

Thank you for taking the time to answer these questions. All together we hold
the key to success!