Parent Input for Student Placement
2011-2012 School Year Smithfield Elementary
Please return this form to your child’s classroom teacher by June 2, 2010
Child’s First Name:
Child’s Last Name:
Name Child Goes By at School (if different)
Parent’s First Name:
Parent’s Last Name:
Email Address:
Date:
Home Phone:
Cell Phone:
Please check the items below that most represent your child’s academic and behavioral
characteristics. This information will be utilized to help select a teacher for your child.
Please do not request a specific teacher.
accepts suggestions & criticisms
appears self-confident
seems popular with friends
follows instructions easily
has anxiety about a new grade level
seems to enjoy school
other:
has poor social skills
cries easily, overly sensitive
has poor self-concept
has difficulty following instructions
is a natural leader
tends to be a follower
other:
Describe the classroom environment in which your child would be most successful.
Describe specific concerns you have for your child (i.e. talkative, overachiever, unmotivated,
nervous, quiet, withdrawn, hyperactive, medical concerns, etc.):
Additional comments pertaining to your child and his/her learning environment: