Emergency Contact And Release From School Information Page 3
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4Parent Questionnaire
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Student Name:__________________________________________ Date of Birth:______________________ Gender:________________
Parent 1 Name:__________________________________________ Parent 2 Name:____________________________________________
1) Please choose any activities in which your child regularly participates (circle all that apply):
Art
Piano
Guitar
Violin
Wind instrument
Dance
Gymnastics
Soccer
Basketball
Football
Tennis
Swimming
Bicycling
Other:_____________________________________________________________________________________
2) What kinds of activities do you do with your child?_______________________________________________________________________
_____________________________________________________________________________________________________________________
3) What approach to discipline do you use (circle all that apply)?
Redirecting behavior
Offering choices
Natural consequences
Conscious Discipline
Punishment & rewards
Explaining why the rules are what they are
Time out ( If you use time out’s, how long?__________)
Other:_______________________________________
4) If you are changing schools, what is your reason for doing so (check all that apply)?
[ ] Not applicable
[ ] Moving
[ ] Location
Seeking any of the following:
[ ] The Montessori Method
[ ] An accredited school
[ ] An individualized approach
[ ] A multi-cultural experience
[ ] Bilingual educational opportunities
[ ] A school that will prepare my child for the most rigorous secondary schools
[ ] Other________________________________________________________________________
5) Were there any discipline issues at any previous schools? If so, please describe the issues here (if no prior schools, write “N/A”):
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
6) Has your child skipped or repeated any grade?
[ ] Yes
[ ] No
If yes, what grade and was it skipped or repeated? ______________________________________
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