Child Special Requirements Form

Address*

,  

Please list any health issues including allergies your child may have. Enter N/A if non-applicable.

Please list any learning disabilities including dyslexia, ADHD, etc., your child may have. Please enter N/A if non-applicable.

List any interests, strengths, or weaknesses.

Are there any circumstances at home that we should be aware of?

Who should we contact in case of an emergency other than yourself?

( )   -

Emergency Contact's Phone Number