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JCC 2023 NOSHC permission slip
One form per child
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* Indicates required question
Email
*
Your email
Student's name
*
Your answer
Student's date of birth
*
MM
/
DD
/
YYYY
Class level
*
Trailblazers
Rainbows
Herons
Sunshines
Explorers
Dreamers
Required
Teacher's name/ Class name
*
Your answer
Has anyone presented any concerns regarding his/her speech and/or language skills? *
*
Yes
No
If you answered YES to the previous question, please further explain
Your answer
Does your child wear glasses? (If yes, please make sure they bring their glasses to school on the day(s) of the screening)
*
Yes
No
Does your child have a history of ear infections?
*
Yes
No
If you answered YES to the previous question, please list the date the most recent ear infection
Your answer
Have Pressure Equalization tubes been placed?
*
Yes
No
If you answered YES to the previous question, please list the date the most recent PE tubes were placed
Your answer
Does your child receive any of the following? (check all that apply)
*
Speech/Language therapy
Language/Processing Therapy
Physical therapy
Occupational Therapy
Play therapy
N/A
Other:
Required
If your child is currently enrolled in therapy, please briefly explain what goals they are currently addressing in therapy.
Your answer
Is there a second language spoken in the home?
*
Yes
No
If you answered YES to the previous question, please list the languages spoken in the home along with the child's primary language.
Your answer
Do you have concerns in any of the following areas: (check all that apply)
*
Speech/Articulation
Receptive Language (e.g., processing, following directions, comprehension)
Expressive language (e.g., answering questions, explaining an event, difficulty organizing his thoughts))
Voice (e.g., hoarse or nasal vocal quality or unable to project)
Fluency (e.g., stuttering, rate of speech)
Pragmatic language (social language skills)
Hearing
Vision
N/A
Other:
Required
Please add any additional concerns
Your answer
Guardian's name who completed this form (By signing this form you are giving permission for NOSHC to screen your child)
*
Your answer
Telephone number
*
Your answer
Does NOSHC have permission to contact you through email?
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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