Midyear Kindergarten Educator Referral FormMidyear Kindergarten Teacher Referral FormThis form is to be completed by the teacher or school.Applicant Name* CHILD’S FIRST NAME LAST NAME DATE OF BIRTH APPLYING TO GRADE Applicant Name* FORM COMPLETED BY: FIRST NAME LAST NAME Applicant Name* POSITION EMAIL PHONE NUMBER Applicant Name* SCHOOL NAME CHILD’S ENROLLMENT START DATE END DATE Applicant Name* LENGTH OF SCHOOL DAY # OF DAYS PER WEEK Applicant Name* WHAT IS THE CHILD’S PRIMARY LANGUAGE? HOW LONG HAVE YOU KNOWN THIS CHILD? I AM THE CHILD'S: CURRENT TEACHER PREVIOUS TEACHER OTHERCHARACTER AND DISPOSITION: PLEASE MARK ALL THAT CONSISTENTLY DESCRIBE YOUR CHILD: EASY GOING CHEERFUL CONFIDENT OBSERVER PATIENT ENTHUSIASTIC ABOUT LEARNING ENTHUSIASTIC ABOUT PLAY DEFIANT CAN’T SIT STILL EASILY FRUSTRATED RESILIENT SLOW TO WARM UP SHORT TEMPERED PHYSICALLY HURFTUL CRIES WHEN FRUSTRATED LEADER FOLLOWER PREFERS PARALLEL PLAY PREFERS LARGE GROUP PREFERS SMALL GROUPWHAT WORDS COME TO MIND TO DESCRIBE THIS STUDENT?WHAT ARE THE STUDENT'S STRENGTHS?WHAT ARE THE STUDENT'S CHALLENGES AND GROWTH AREAS?DESCRIBE THIS STUDENT'S APPROACH TO LEARNING (HANDS ON, VISUAL, KINETIC, AUDITORY, LOGICAL). WHAT MOST ENGAGES THIS CHILD?DESCRIBE THE STUDENT'S ABILITY TO DEVELOP FRIENDSHIPS AND RESOLVE CONFLICTS:DEVELOPMENT: FOR EACH ITEM LISTED BELOW, PLEASE CHOOSE THE MOST APPROPRIATE DESCRIPTION:SPEECH IS EASILY UNDERSTOODCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEPOSITIVE INTERACTION WITH PEERSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEPOSITIVE RELATIONSHIPS WITH ADULTS/TEACHERSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEAWARE OF OTHERS' NEEDS, SHOWS EMPATHYCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEUSES WORDS TO RESOLVE CONFLICTCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEABLE TO SOLVE PROBLEMS WITHOUT ADULT HELPCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEDEMONSTRATES BODY AND SPACE AWARENESSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEDEMONSTRATES FINE MOTOR COORDINATIONCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEABLE TO VERBALLY COMMUNICATE FEELINGS, NEEDS, IDEASCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVESHOWS RESPONSIBILITY FOR BELONGINGSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEDEMONSTRATES SELF-HELP SKILLSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEIS WILLING TO PARTICIPATE IN ROOM CLEAN-UPCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEAPPROACH TO LEARNING: FOR EACH ITEM LISTED BELOW, PLEASE CHOOSE THE MOST APPROPRIATE DESCRIPTION:COMPLETES TASKSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEMAKES TRANSITIONS EASILYCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVELISTENS AND FOLLOWS DIRECTIONSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEDEMONSTRATES ATTENTION SPAN FOR TEACHER-LED ACTIVITYCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEDEMONSTRATES ATTENTION SPAN FOR TEACHER-LED ACTIVITYCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEDEMONSTRATES ATTENTION SPAN FOR SELF-CHOSEN ACTIVITYCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEABLE TO WORK AND PLAY INDEPENDENTLYCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEABLE TO WORK AND PLAY COOPERATIVELYCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEABLE TO BE REDIRECTED BY TEACHERCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEABLE TO STAY ON TASKS WITHOUT TEACHER SUPPORTCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVETRIES NEW ACTIVITIES OF OWN CHOICECONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVETRIES NEW ACTIVITIES THAT ARE TEACHER-DIRECTEDCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEFAMILY ENGAGEMENT: FOR EACH ITEM LISTED BELOW, PLEASE CHOOSE THE MOST APPROPRIATE DESCRIPTION:SEPARATES EASILY FROM PARENT/GUARDIAN(S)CONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEPARENT(S) SET APPROPRIATE LIMITS WITH CHILDCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEPARENT(S) ARE RESPONSIVE TO FEEDBACK AND RECOMMENDATIONSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEPARENT(S) HAVE REALISTIC EXPECTATIONS OF CHILDCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEPARENT(S) CONTRIBUTE TO THE CLASSROOM AND PARTICIPATE IN SCHOOL ACTIVITIESCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEPARENT(S) SUPPORT SCHOOL PROCEDURES AND EXPECTATIONSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEPARENT(S) ARE RESPECTFUL OF TEACHER'S TIME (I.E. ON TIME ARRIVAL/PICK-UP)CONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEDESCRIBE THE FAMILY'S PARTICIPATION IN THE SCHOOL COMMUNITY:IS THERE ANY INFORMATION PERTAINING TO THIS CHILD/FAMILY THAT WOULD BE BETTER COMMUNICATED BY PHONE? YES NOTHE BEST NUMBER AND DAYS/TIMES TO REACH ME ARE:Δ
