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RRPPS Child Search Information Form
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* Indicates required question
Email
*
Your answer
Child's Name: (LAST NAME, FIRST NAME)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Main Concerns
*
Academics
Audiological/Hearing
Autism
Behavior
Health Concerns
Large or Small Motor Skills
Social Skills
Speech/Articulation/Language/Vocabulary/Non-Verbal
Vision
Gifted Screening
Other:
Required
Explanations of concerns, if needed:
Your answer
Mother/Guardian's 's Name
Your answer
Mother/Guardian's Cell/Work Number
Your answer
Parent/Guardian Relationship: (Mother)
Parent
Step-Parent
Legal Gaurdian Court Appointed
Foster Parent
Grandparent
Other:
Clear selection
Father/Guardian's Name:
Your answer
Father/Guardian's Cell/Work Number
Your answer
Parent/Guardian Relationship: (Father){
Parent
Step-Parent
Legal Guardian Court Appointed
Foster Parent
Grandparent
Other:
Clear selection
Street Address:
*
Your answer
City, State, Zip Code
*
Your answer
Legal Guardian (Select All That Apply):
*
Mother
Father
Foster Parent
Other:
Required
Military?
Yes
No
Clear selection
Evaluated Before?
Yes
No
Other:
Clear selection
If Yes, Explain Prior Evaluations Here:
Your answer
Ethnic Group/Race (Select All That Apply:
*
Hispanic/Latino
American Indian
Alaskan Native
Asian
Black/African American
Native Hawaiian/or Other Pacific Islander
White
Other:
Required
Child's Social Security Number:
Your answer
Medicaid (If Applicable:
Your answer
Referred by:
Your answer
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