Student Intake FormStudent InformationFirst NameLast NameSchool Attending *Birth Date *Current GradeCurrent GradeKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeAllergies *NoYesParent / Guardian InformationFirst NameLast NameRelationship *Phone *Email Address *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeGeneral InformationPlease check all the appropriate items that apply to your student *Note: At least 1 box must me checked. Check all that apply. If “Other” is selected, it must include a free form explanation to be validatedHas the student repeated a gradeIs there a family history of learning problemsSlow reading speedDifficulty comprehending informationDelayed speakingTrouble remembering abbreviationsTendency to avoid readingFrustration when readingPreference for read aloud answersDifficulty with handwritingAttention deficit hyperactivity disorder (ADHD)Difficulty rhymingDifficulty pronouncing wordsPoor auditory memory for nursery rhymesUnable to recall the right wordsSlow to add new vocabularyOtherHas your student been diagnosed with any learning disabilities? *NoYesDoes your student have a IEP at school? *YesNoDoes your student’s school have special support in the classroom for your child? *YesNoDisclosure & Authorization Statement *By submitting this form, I acknowledge and authorize Strands of Accelerated Reading (SOAR) to collect and store the educational information provided about my child for the purposes of conducting an initial consultation and developing appropriate recommendations for support.I understand that:This information will be kept confidential and will not be shared with any third parties without my explicit written consent.If my child enrolls in services with SOAR, this information may be used as a reference point to track progress and support ongoing instruction.If my child does not move forward with SOAR, the information will be securely stored only in relation to this consultation record.I may request access to, correction of, or deletion of my child’s information at any time by contacting SOAR directly.By submitting this form electronically, I confirm that I am the parent/legal guardian of the child named in this form and that I consent to SOAR’s collection, storage, and use of this information as described above.SubmitPlease do not fill in this field.
