Child First Name*
Child Last Name*
Gender Pronouns preferred If "Other," specify
Primary Address*
If "Other," please specify
What is your child's primary language?*
Please list other languages spoken at home.
Known Allergies*
Emergency Contact #1 Name and Number*
Emergency Contact #2 Name and Number*
Please list any additional people authorized to pick up your child.
First Name*
Last Name*
Relationship to Student*
Address (if different from child's)
If 'Other', please specify
Email*
Phone Number*
Full Name/Relationship
Address (if different from child's)
If 'Other', please specify
Parent/Guardian #2 Phone Number
Parent/Guardian #2 Email
Please describe your child's personality*
What are their favorite activities/interests?*
Please describe your child's strengths.*
How does your child communicate that they are frustrated or need a break?*
When your child hangs out with friends (choose all that apply):* If 'Other', please specify
What are some experiences your child struggles with (situations, games, topics, sensory input, etc.)?*
Name of current school*
Past school(s) attended
Has your child been evaluated through school?* If your child has been evaluated, please list the name of the school, areas evaluated and date(s).
Please describe your child's current school struggles:*
How would you describe your child's learning style?*
What helps child have a "good day" at school (set schedule, repeated breaks, snacks, etc)?*
Please describe any behavior or attention struggles your child is having at school. *
Does your child have an IEP or 504 goals?* If yes to having an IEP or 504 goals, please upload here: Has your child received speech and language therapies?* Please describe any conerns you have had, or currently have, about your child's speech, language, or communication abilities.
Has your child received occupational therapy?* If 'Other', please specify
Has your child received adaptive P.E.?* If 'Other', please specify
Please list any concerns you have had or currently have about your child's fine or gross motor abilities.
How do you hope the Samara Learning Center can help you child?*
Who lives at home with your child?*
What are your child’s chores and responsibilities at home?*
Please describe your chid's behavior at home (ex: quiet, avoids interactions, joiner, outspoken, energetic, etc.).*
What do you consider to be some of your family's values?
Describe your child's current health*
Does your child have any allergies? If so, what are they?*
Please list any medications that might affect your child during the school day.*
Has your child received therapy/counseling/mental health services?* If 'Other' please specify
Please add other medical information that you feel would be helpful.
I agree to allow a hospital or doctor to treat my child without parent's consent (if a matter of life or death).* If "Other," specify
Insurance Company Name*
Enrolled Member Name and DOB*
Policy Number & Group Number*
The Samara Learning Center, Samara’s collaborators, and/or news/information based publications may post photographs and/or videos of my child and their work on electronic media and promotional/news/informational material, including but not limited to: web pages, social media, or newspaper/magazine articles. *
Agency or individual (name and role)
Complete Address
Phone & email
The purpose of the exchange of information is on-going program planning and continuation of care. If "Other," specify
Type of information exchanged If "Other," specify
The period of release is valid for: If "Other," specify
Parent/Guardian Printed Name
Parent/Guardian Signature
Child's name
Agency or individual (name and role)
Complete Address
Phone & email
Purpose of the exchange of information is on-going program planning and continuation of care. If 'Other', please specify
Type of information exchanged If "Other," specify
The period release is valid for: If "Other," specify
Parent/Guardian Printed Name
Parent/Guardian Signature