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Willard Public Schools Early Childhood Special Education Peer Model Application (rev. 2/10/20)
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* Indicates required question
Email
*
Your email
Child's Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Place of Birth
*
Your answer
Father's Name
*
Your answer
Mother's Name
*
Your answer
Step Parent or Guardian Name
Your answer
Address
*
Your answer
Phone Number
*
Your answer
Email Address
Your answer
Father's place of employment
Your answer
Father's employment phone
Your answer
Mother's place of employment
Your answer
Mother's employment phone
Your answer
How many children are in the home?
Your answer
Other Person's Living in the home?
Your answer
Has your child attended preschool or daycare? If yes, where?
Your answer
Did your child participate in Parent's As Teachers?
Yes
No
Clear selection
Indicate your preference of class location for your child.
Willard North
Willard Orchard Hills
Clear selection
Indicate your preference for the session your child would attend.
My child must attend the morning session.
My child must attend the afternoon session
I prefer the morning session, but could do the afternoon
I prefer the afternoon session, but could do the morning
I have no preference
Clear selection
Please tell us about your child's strengths.
Your answer
Please tell us about any concerns you may have regarding your child (health, allergies, etc.)
Your answer
If your child were a peer in one of our classrooms, where would she/he spend the other half days and Fridays?
I am unsure
With family
At a daycare
Clear selection
Which best describes your child's personality?
Fearful and clingy
Shy and quiet
Outgoing and happy
Other:
Clear selection
How does your child get his/her needs met?
Cries and goes to an adult
Tries things on his/her own
Asks an adult for support or permission
Clear selection
Describe your child's self help needs.
Does not dress self, needs help with the bathroom
Will take care of needs if expected to, but doesn't want to
Dresses self, toilets independently, eats with little spillage, puts coat on
Clear selection
Does your child follow rules and expectations?
This is a concern of mine. He/she has to be told several times and needs warnings.
He/she needs some reminders, but will comply
He/she does what is asked without much complaint
Clear selection
How does your child respond to frustrating events?
Cries and/or becomes quite upset
Requires some support and comfort
May be unhappy, but is able to accept the situation
Clear selection
I understand that I am responsible for my child's transportation
Yes
No
Clear selection
Submit
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