Special Needs Information

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At Creekside Academy Learning Cooperative, we want to celebrate the uniqueness of each child.  Thank you for your help by informing us of your child's special needs.

Find a printable PDF form here.
1. *

Child's name
2. *

Parent's Names
3. 

Allergies:
4. 

List any medical conditions of which we need to be aware.
5. 

Specific Needs: Place a check mark beside the specific needs of your child in a co-op class.

 
Help with reading Help with writing
Help with cutting or other fine motor skills Adaptations related to vision
Adaptations related to understanding language Special Equipment
An individual to help Other
6. 

Check any applicable information that might be helpful for volunteers/teachers to best minister to your child.

 
Short attention span/easily distracted Temper tantrums
Aggressive behavior Difficulty with changes in routine
Shyness Difficulty following directions
Difficulty with fine motor (cutting/pasting) Special bathroom needs
Difficulty completing activities Needs visual presentations
Cannot read Difficulty sitting in a group
Issues with separation anxiety Tend to run (leaves room without permission
Tends to be possessive Separation anxiety
7. 

List things your child does well.
8. 

List things that are hard for your child.
9. 

List helpful suggestions for people working with your child.
10. 

If your child is having a difficult time, at what point do you want to be notified?
11. 

Add any additional information that would be helpful to people working with your child.
12. *

Permission/Authorization Agreement:

  • I have fully disclosed all pertinent information about my child’s special needs and accept full responsibility for missing information.
  • I will supply special food, drinks, snacks, diapers/wipes for child as necessary.
  • I do hereby release Creekside Academy Learning Cooperative and its representatives of any liability due to accident or injury incurred by my child.

Please click on "Agree" below.

Celebrating the uniqueness of each child.

I praise you because you made me in an amazing and wonderful way...

  Psalm 139:14

Thank you for completing the special needs information sheet concerning your child.  Please print a copy of the completed form to give to each of your child's teachers at orientation.
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