Please Describe:

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:

Do you have any concerns about your child's expressive or receptive language skills?

Please Describe:

Does your child have any physical restrictions?

If yes, please describe:
 

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

Does your child have opportunities to play with other children? YesNo

Please describe:

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

If yes, please describe:
 

Does your child have difficulty separating from familiar adults? YesNo  

If yes, please describe:
 

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.