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Hebrew School Student Profile 2022-23
Please verify reCaptcha before submitting the form.
First Name:
Last Name:
Email:
CONFIDENTIAL STUDENT PROFILE ‐‐ SCHOOL YEAR 2022‐2023
*This form will be used for educational planning purposes only. Content will be viewed only by relevant educational staff and/or providers of direct or indirect educational services.
The CSAIR Marsha Dane Stern Hebrew School is committed to providing a quality Jewish education to every student, regardless of learning style or special learning needs. Please answer the questions below to help us create learning experiences that best fit the needs of each of our learners.
ACADEMIC BACKGROUND
Please fill out a form for each child attending the Marsha Dane Stern Hebrew School.
How many children do you have attending Hebrew School:
1 Child
2 Children
3 Children
4 Children
Child's Name 1:
Date of Birth:
Grade:
Please share with us how your child learns best:
Does your child have an IEP?
No
Yes
Does your child have a 504 plan?
No
Yes
If your child receives special accommodations through their IEP or 504 please list accommodations:
*Please provide a copy of the IEP and/or 504 plan.
RELATED SERVICES
Did your child receive any related services at school in the past academic year?
No
Yes
If yes, please share with us what related services were received:
Speech & Language
Occupational Therapy
Physical Therapy
Counseling
Resource Room
Pull Out
Collaborative Teaching
One on One Aide
Other
If other, please elaborate:
Has your child ever received professional counseling?
No
Yes
If YES, please answer the following questions:
1. How long has your child received counseling?
2. For what purpose was your child receiving counseling?
If yes, may we contact your child’s Psychologist/Psychiatrist/Counselor?
No
Yes
Contact Information of Psychologist/Psychiatrist/Counselor:
Please include Contact Name, Phone and Email.
Additional Information:
Please share any additional information or comments that may provide our staff with further insight into
your child’s personality and character and help us provide a successful experience for your child:
Child's Name 2:
Date of Birth:
Grade:
Please share with us how your child learns best:
Does your child have an IEP?
No
Yes
Does your child have a 504 plan?
No
Yes
If your child receives special accommodations through their IEP or 504 please list accommodations:
RELATED SERVICES
Did your child receive any related services at school in the past academic year?
No
Yes
If yes, please share with us what related services were received:
Speech & Language
Occupational Therapy
Physical Therapy
Counseling
Resource Room
Pull Out
Collaborative Teaching
One on One Aide
Other
If other, please elaborate:
Has your child ever received professional counseling?
No
Yes
If YES, please answer the following questions:
1. How long has your child received counseling?
2. For what purpose was your child receiving counseling?
No
Yes
Contact Information of Psychologist/Psychiatrist/Counselor:
Please include Contact Name, Phone and Email.
Additional Information:
Please share any additional information or comments that may provide our staff with further insight into
your child’s personality and character and help us provide a successful experience for your child:
Child's Name 3:
Date of Birth:
Grade:
Please share with us how your child learns best:
Does your child have an IEP?
No
Yes
Does your child have a 504 plan?
No
Yes
If your child receives special accommodations through their IEP or 504 please list accommodations:
*Please provide a copy of the IEP and/or 504 plan.
RELATED SERVICES
Did your child receive any related services at school in the past academic year?
No
Yes
If yes, please share with us what related services were received:
Speech & Language
Occupational Therapy
Physical Therapy
Counseling
Resource Room
Pull Out
Collaborative Teaching
One on One Aide
Other
If other, please elaborate:
Has your child ever received professional counseling?
No
Yes
If YES, please answer the following questions:
1. How long has your child received counseling?
2. For what purpose was your child receiving counseling?
If yes, may we contact your child’s Psychologist/Psychiatrist/Counselor?
No
Yes
Contact Information of Psychologist/Psychiatrist/Counselor:
Please include Contact Name, Phone and Email.
Additional Information:
Please share any additional information or comments that may provide our staff with further insight into
your child’s personality and character and help us provide a successful experience for your child:
Child's Name 4:
Date of Birth:
Grade:
Please share with us how your child learns best:
Does your child have an IEP?
No
Yes
Does your child have a 504 plan?
No
Yes
If your child receives special accommodations through their IEP or 504 please list accommodations:
*Please provide a copy of the IEP and/or 504 plan.
RELATED SERVICES
Did your child receive any related services at school in the past academic year?
No
Yes
If yes, please share with us what related services were received:
Speech & Language
Occupational Therapy
Physical Therapy
Counseling
Resource Room
Pull Out
Collaborative Teaching
One on One Aide
Other
If other, please elaborate:
Has your child ever received professional counseling?
No
Yes
If YES, please answer the following questions:
1. How long has your child received counseling?
2. For what purpose was your child receiving counseling?
If yes, may we contact your child’s Psychologist/Psychiatrist/Counselor?
No
Yes
Contact Information of Psychologist/Psychiatrist/Counselor:
Please include Contact Name, Phone and Email.
Additional Information:
Please share any additional information or comments that may provide our staff with further insight into
your child’s personality and character and help us provide a successful experience for your child:
Wed, April 24 2024 16 Nisan 5784
