Family History Survey
Student Name
*
First Name
Last Name
Student Birthdate
*
-
Month
-
Day
Year
Date
Student Grade
*
What is your child’s interest in reading and literacy activities such as reading independently, having books or stories read to them, and rhyming activities?
*
Very Uninterested
Uninterested
Somewhat Interested
Interested
Very Interested
Has your child ever been recommended for summer reading intervention or support?
*
Yes
No
If so, who made the recommendation?
Has your child ever been recommended to receive reading or writing tutoring services outside of the school setting?
*
Yes
No
If so, who made the recommendation?
Has anyone in the child’s family experienced difficulties with reading and spelling or been diagnosed with dyslexia (either as a child or adult)?
*
Yes
No
Submit
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