Student Questionnaire

Student Questionnaire for Children with Special Needs

This questionnaire is meant to assist The Rose Theater staff in creating the best possible class experience for children with autism and other specialized needs. Please complete those sections that are pertinent to your child.

My child's full name is:*
My child prefers to be called
The pronouns my child uses are:

(She/Her/Hers, He/Him/His, They/Them/Theirs, etc.)
Student Age
Please share your child's diagnosis.
Will your child need an ASL interpreter?
- Yes
- No
Are there additional services your child will need?
Are there any strategies or recommendations you would like to share for helping your child be successful in our classrooms?
Anything else you'd like us to know?
The Rose Theater's Touching Policy
Please share the following with your child.
The Rose Theater education staff's touching policy for students is only above the shoulders and below the knees. In order to ensure student safety, when/if student’s exhibit behavior that endangers other students or puts their safety at risk, instructors reserve the right to speak with parents regarding dismissal of the student. If your child uses security hugs or any other techniques, please speak with an educator, list them below and indicate if you would like to give consent for teachers to use if circumstances necessitate it.*
- I have read the above information and will share it with my child.
Does your child use security hugs or other forms of physical touch?*
- Yes
- No
If yes, please summarize these techniques:
Do you give permission for Rose educators to implement these techniques?
- Yes
- No
If yes, we ask that you please discuss these techniques with your student's teacher.
Parent's Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
Untitled

Classes for Children with Exceptionalities Find Classes

Student Questionnaire

Student Questionnaire for Children with Special Needs

The Rose Theater's Touching Policy