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The purpose of this form is to gather information prior to the studentís participation in our Special Needs Taekwondo Program. This information may help us to develop the most appropriate program plan for your child. Your input is extremely valuable. Please take a few moments to complete the following questions, please be specific and thorough, and return to Master Ro as soon as possible.

Studentís Name__________________________ Nickname________________ Date of Birth________

Address___________________________________________________ Home Tel. #_______________

Parentís / Guardianís Name & Cell # __________________________________________________

Parentís / Guardianís Email __________________________________________________

Child's School / Grade / Teacherís Name______________________________________________

Please take a few moments to complete the following questions, and return this form by email or fax.

1) What should we know about your child that would assist us in teaching him/her? Such as:

a) Cognitive abilities. This should include your child's ability to reason, remember, and understand.


b) Behavior. Childís ability to pay attention; the quality of child's relationships with children and adults.


c) Physical abilities. This should include an assessment of your child's health, including vision, hearing, communication abilities, and the ability to move purposefully. ___________________________________


d) Development. This should include your child's progress in a number of areas such as understanding and responding to language, social and emotional abilities, sensory perception, and mobility. ____________


2) What are your childís present levels of functional performance? ________________________________

3) What motivates your child? ________________________________________________________________

4) What methods would you suggest we use to motivate your child in class? ________________________


5) What methods would you suggest we use to get your child to cooperate in class? __________________


6) Are there areas of concern regarding your child that we should be aware of?

a) When he/she is at home? _______________________________________________________________

b) When he/she is at school or participating in an after school activity? __________________________


c) What methods have you used to address the concern(s) noted above? ________________________


d) Would they be successful for us to utilize in class, if needed? _______________________________

7) What is/are the most important goal(s) that you would like to see accomplished with our Taekwondo program? _____________________________________________________________________________

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8) What else can you tell us about your child that would be useful for us to get to know and work with your child?

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