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.