Student’s Personal Information Name(Required)
First
Last
Address(Required)
Gender(Required)
Part 1: Concept Development
Part 2: Physical Development
Part 3: Health and Safety
Part 4: Number Concept Development
Part 5: Language
Part 6: Reading
Part 7: Writing
Part 8: Social & Emotional Development
Parent/Guardian Information 1st Parent or Guardian Name(Required)
First
Last
Address same as applicant's?(Required) 1st Parent/Guardian Address
1st Parent/Guardian Email(Required) 2nd Parent or Guardian Name
First
Last
Address same as applicant's? 2nd Parent/Guardian Address
2nd Parent/Guardian Email
Additional Parental Information Parents’ marital status Legal custody Physical custody Name
First
Last
Gender Name
First
Last
Gender Name
First
Last
Gender Name
First
Last
Gender Name
First
Last
Gender Name
First
Last
Gender Please list the languages spoken in the home
Educational History School Address
With respect to your child’s current grade, please describe his/her greatest achievements and most significant challenges.(Required)
Has the applicant attended any additional schools?(Required) Please include all schools attended from preschool on.
School Address
School Address
School Address
School Address
School Address
School Address
Behavioral and Educational Background Strengths(Required) What are your child’s strengths?
Personality(Required) Please describe your child’s personality (i.e. social interactions, motivators, general attitude, habits).
Hobbies and interests(Required) What are your child’s hobbies and interests?
Academic Skills and Challenges(Required) Please describe your child’s academic skills and challenges.
Student Citizenship Skills and Challenges(Required) Please describe your child’s student citizenship skills and challenges. (i.e. ability to sit at a desk, raise a quiet hand, participate in group lessons, etc.)
Communication skills(Required) Please describe your child’s communication skills.
Self help skills(Required) Please describe your child’s self help skills (including eating, dressing, bathing, sleeping, toileting).
Behavior(Required) Please describe any disruptive or maladaptive behavior your child exhibits. Include whether you see those behaviors at home or at school. Please describe your child’s behavior when he or she is in the “yellow” zone as well as in the “red” zone.
Behavior Frequency(Required) How often does your child exhibit the behaviors described above?
Triggers(Required) What are some of the triggers that can result in challenging behavior for your child?
Motivators(Required) Are there special privileges that are motivating for your child? If so, what are they?
Social relationships(Required) How does your child relate to family members? Friends? School faculty? Strangers?
Community interactions(Required) Does your child participate in community groups such as soccer, camp, etc? If so, please describe those interactions.
Optimal learning environment(Required) Describe what you feel is the optimal learning environment for your child.
Areas of greatest need(Required) What are your child’s areas of greatest need?
Areas of concern(Required) Are there additional areas of concern of which we should be aware?
Additional information(Required) What else would you like us to know about your child?
Tactile sensitivity(Required) Reports that things “feel funny” and/or has specific preferences for clothing or blankets of a certain feel
Tactile sensitivity(Required) My child’s tactile sensitivity causes him or her regular distress or disruptions to his/her day.
Auditory sensitivity(Required) Reports that sounds bother him or her, has difficulty screening out noises
Auditory sensitivity(Required) My child’s auditory sensitivity causes him or her regular distress or disruptions to his/her day.
Orientation(Required) Not orientated to what is going on in the moment, in their own world for the moment.
Orientation(Required) My child tends to be in his/her own world especially during non-preferred activities.
Gross motor challenges(Required) My child often bumps into things or exhibits difficulty riding a bike, playing sports, or other gross motor challenges.
Fine motor concerns other than writing(Required) My child exhibits difficulty with fine motor tasks such as working with Legos, buttoning a button, picking up small items.
Easily tired, little stamina in physical activity(Required) Poor ability to read facial or behavioral cues of others(Required) Inflexible(Required) Believes rules are black and white, intolerant of changing rules or rules not meeting expectations.
Finds it difficult to bounce back when upset(Required) Easily frustrated(Required) Limited ability to tolerate feelings of frustration without acting out.
Aggression towards objects(Required) Throws things, knocks over furniture, but does not aim at persons.
Verbal aggression(Required) Name calling, inappropriate/rude language, insults, antagonism.
Low level physical aggression towards peers(Required) May make light contact such as shoving, elbowing.
How many times per week might your child exhibit this behavior? Low level physical aggression towards adults(Required) May make light contact such as shoving, elbowing.
How many times per week might your child exhibit this behavior? Medium level physical aggression towards peers(Required) May hit, kick, scratch. May be painful and leave a bruise but does not result in significant physical injury.
How many times per week might your child exhibit this behavior? Medium level physical aggression towards adults(Required) May hit, kick, scratch. May be painful and leave a bruise but does not result in significant physical injury.
How many times per week might your child exhibit this behavior? High level physical aggression towards peers(Required) Results in injury needing medical attention.
How many times per week might your child exhibit this behavior? High level physical aggression towards adults(Required) Results in injury needing medical attention.
How many times per week might your child exhibit this behavior? Please describe any major behavioral incidents that has occurred in the last 6 months, or any incident in which authorities had to be called or someone was injured, regardless of recency.(Required) If none, please write “None".
Meltdowns(Required) Experiences meltdowns that may include lack of awareness of what they are doing, loss of control
How many times per week might your child exhibit this behavior? Rigidity, inflexible thinking(Required) Has significant fears or phobias that exceed actual threat and interfere with daily activities(Required) Has difficulty leaving preferred activity(Required) Struggles with transitions to the point of interfering with daily activities(Required) Personal space violations(Required) Invades others’ personal space in a way that makes people take a step back or ask for space
Excessive off topic comments(Required) Excessive interruptions(Required) Difficulty in seeing another person’s perspective(Required) Fidgety – cannot sit still(Required) Physical regulation challenges(Required) Has trouble controlling physical actions
Emotional regulation challenges(Required) Refusal to attend and/or leave school(Required) Difficulty attending during instruction(Required) Needs one-on-one support to complete tasks(Required) Requires frequent redirection for activities that they have the skill and knowledge to complete(Required) Tests boundaries more than others his/her age(Required) Has trouble starting tasks(Required) Has trouble finishing tasks(Required) Easily overwhelmed(Required) Disruptive(Required) Very sensitive to slights or comments(Required) Cries easily(Required) Clingy(Required) Worries about academic performance disproportionate to skills(Required) Is frequently sad(Required) Is frequently withdrawn(Required) Is frequently irritable(Required) Expresses hopelessness(Required) Express not wanting to be alive, that they would be better off in the next life, talks of self harm(Required) Acts in a way that may harm self(Required) Expresses sense of worthlessness(Required) Difficulty concentrating except in most preferred activities (like screens)(Required) Has stopped enjoying activities that they used to like (with the exceptions of an activity that they have grown out of)(Required) Uses technology devices to self-regulate(Required) Has had a recent drop in grades(Required) Recent changes in friendships(Required) Wants to leave the classroom or school frequently(Required) Please check all the words that describe your child regularly
Additional information Is your child on a special diet? Description of special diet
Allergies Please list any allergies to medications, foods, animals, etc.
Please describe your volunteer efforts at your child/children’s school(s).(Required)
How did you hear about The Burkard School?
