Confidential* Parent/Guardian Survey
Student name ________________________________Class/Grade________________
Your name____________________________________________________________
Relationship__________________________________________________________
Address_____________________________________________________________
Home phone #:______________Other # (optional):____________________________
Email Address (optional)_________________________________________________

What do you believe are your child’s strengths? What do you believe are your child’s needs?




What activities is your child involved with outside of the school day? (religious, community, arts, other)



Is there a particular time of the year that your child may require additional support due to their religious, cultural, medical and/or other obligations?



What goals do you have for your child this year?



Is there any other critical information regarding your child’s learning that would you like to provide? (medication, outside counseling, personal experience, etc.)


What mode of communication do you prefer? (phone calls, notes, email, etc.)


What questions/concerns do you have about your child’s progress this year?


Is there any other information that you would like to share?