BIC Religious School
Confidential Information: Please answer these questions to help us meet your child's unique needs. The information you share in this section of the form will be kept confidential. It will be shared with your child's teacher with your permission only when necessary to help us achieve a safe and positive learning environment for your child.
I give my permission for this information to be shared with my child's teacher.
Please list all allergies (if none write none)
Please list medications your child takes regularly
Please check any that apply. For any checked item, please explain related classroom challenges or opportunities in the field below. My child:
Is hearing impaired
Has a speech impediment
Is unusually active
Has a short attention span
Is easily upset
Is academically gifted
Reads below grade level
Has a diagnosis of ADD or ADHD
Has an auditory or language processing disorder (APD or LPD)
Has a diagnosis of Dyslexia
Has a diagnosis of Autistic Spectrum Disorder or Pervasive Developmental Disorder (ASD or PDD)
Has an IEP/GIEP
Other (describe below)
None of the above
Any special situations of which we should be aware?
What are your goals for your child's religious education this year?
I have questions, concerns, or additional information to share about my child. Please have Rabbi Kassoff contact: