2022-2023 Marysville Schools Preschool Peer Model Program Intake Form

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The Marysville School District provides early childhood education for young children with disabilities. To help provide a well rounded experience, Marysville Schools welcomes peer models within the classrooms. Peer models are typically developing children ages 3 ½ years old -5 years old displaying strong skills in socialization/leadership, communication/language skills and are toilet trained. Peer models should also be able to independently listen and follow teacher direction and interact with peers using cooperative play strategies within the classroom environment. Please complete the below form if you are a Marysville Schools resident and would like your child to be considered for Marysville Schools Preschool Peer Model Program for the 2022-2023 School Year.

Email *

Child's Last Name *

Child's First Name *

Child's Nickname

Date of Birth *

YYYY

Parent(s)/Guardian(s) Name *

Are one of the parents an employee of MEVSD? *

Yes

Other:

Are you interested in participating during the current school year (2022-2023)? *

Yes

Address *

Parent/Guardian Phone Number *

Parent/Guardian Phone Number

Parent Guardian Email Address *

Parent Guardian Email Address

Class Preference *

9:10-11:30 AM

1:00-3:50 PM

List other preschool or group experiences

How does your child separate from parents? *

Is your child the sibling of a current enrollee in our program? *

Yes

If yes, who is the student?

Please list your child's allergies if any: *

Please complete the following checklist. Check all items that describe your child: *

Eats and drinks independently

Dresses self except shoes

Independent with toileting needs (may need help with difficult snaps)

Verbally interacts with peers in a play situation

Speech is clear and understandable by unfamiliar adults

Responds to simple questions

Can follow simple directions

Speaks in sentences

Shows understanding of how things work by turning things on/off, activating a variety of toys or direction adults to do so

Independently picks up small toys

Uses toys and objects appropriately

Uses imagination in play

Will share toys and cooperate in play

Takes turns with minimal assistance

Required

Does your child eat and drink independently? *

Yes

Does your child dress self except shoes? *

Yes

Is your child independent with toileting needs (may need help with difficult snaps)? *

Yes

Does your child verbally interact with peers in a play situation? *

Yes

Does? *

Yes

Please describe your child's strengths *

Please describe your child's weaknesses *

What are your child's interests? *

Is your child a leader or a follower? *

How does your child respond to directions given from and adult? *

How do you predict your child will react in the classroom (i.e. shy, outgoing, quiet)? *

How does your child interact with other children his/her age? *

Why would you like your child to be enrolled as a peer model? *

Is there any other information that you would like to share with us about your child? *

Send me a copy of my responses.

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