Student Name: ________________________________________ Student Placement Information
Submitted by Parents/Guardians
Current Grade & Teacher: _______________________________ School Year 2010-2011
This form is not required.
Learning Style/Needs
Please check all that apply:
1. My child works well with others most of the time (in whole and small instructional groups) .____
2. My child prefers to work in an independent manner most of the time.____
3. My child is successful within a structured environment.____
4. My child is successful when presented with material that is multi-sensory and ‘hands-on’ in
nature.____
5. My child is successful when visual models are presented with instruction.____
6. My child prefers to learn through listening.____
Social/Emotional Needs
Please check all that apply:
1. My child responds well to routines, rules and structure.____
2. My child needs encouragement to try new activities.____
3. My child is considered to be shy.____
4. My child is considered to be an outgoing child.____
5. My child is able to advocate for his/her needs.____
6. My child responds well in a nurturing environment.____
We always try to place each child with someone he/she knows from the previous school year. However,
there are times when children should not be placed together (even the best of friends can be a
distraction to one another). If you have this type of request, please indicate below:
My child should be separated from:_______________________________________.
Multiple children (i.e. twins):
I want my twins in (circle one) the same or different classrooms
Parent/Guardian Signature Date
Please return your form to Larry Fliegelman, Principal. All forms due by April 16th.
Please be aware that I do share theses with the teachers.
Please note that I am unable to accept any teacher specific requests.