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Learning Together: An Inclusive 3 Year-Old Program

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Fill out the form below to apply for 2016-17 School Year



Click here to view flyer
Click here for a printable application
Apply
 
 
 

*Child must be at least three years old on September 1.

 
 
 
 
 
 
   
 
 
 
   



 

 
 

Please Describe:



Developmental Information:

Is your child speaking in 4-5 word sentences?

 

Provide an example:

 

Does your child follow simple directions given by an adult?

 

Explain, if needed:

Does your child have any physical restrictions?

 

If yes, please describe:
 

Is your child toilet trained? *children must be independent in the bathroom.

 
Social, Emotional, and Behavioral Characteristics:

Does your child have opportunities to play with other children?

 

Please describe:

Do you have concerns about your child's play or social skills?  

If yes, please describe:
 

Does your child have difficulty separating from familiar adults?  

If yes, please describe:
 

Learning Style, Motivators, and Reinforcers
My child does best when:  
My child enjoys or is interested in:  
My child does not like or avoids:  
I would like my child to learn or improve:  

The following information about my child may be helpful to the decision-making process:

I give my permission for the Learning Together team to use information on this form in the decision making process related to participation in the Learning Together Program. I understand that this information will be kept confidential and cannot be read by anyone other than the Harford County Public School personnel who have a legitimate educational interest. I am aware that this information may not be sent to anyone outside of Harford County Public Schools without my written permission and that I may request that this information be removed from my child’s records if it is inaccurate, misleading, or otherwise in violation of the privacy or other rights of my child. I am also aware that I may request a copy of this completed form for my own records.

Signature of Parent of Guardian(Type Name)
 
Date