Lighthouse International Referral Form

Please fill out this form for each enrolling learner.

Email *

Your Name *

Best Contact Number *

Child's Name *

In what capacity do you know this child? *

For how long have you known this child? *

Child Attributes Evaluation *

Question	Area of Concern	Progressing towards age-appropriate	Age-appropriate	Strength
Self-confidence
Self-control
Accepts responsibility for behavior
Stands up for rights
Solves problems constructively
Is considerate
Cooperates with adults
Plays cooperatively with peers
Finds ways of entering group play
Respects the rights and property of others
Respects the needs of others
Respects the needs of others
Supports peers
Shares
Takes turns
Is able to make choices
Willing to try new activities
Makes transitions
Responds positively to constructive criticism
Initiates play
Is able to lead
Is able to follow
Is able to follow
Is attentive
Is curious
Can concentrate
Works independently
Works independently
Works cooperatively
Listens in a group
Willing to try the unknown
Adjusts to routines and rules
Exhibits problem-solving ability
Responds to child-initiated activities
Completes tasks
Focuses on one task
Moves easily from one task/activity to another
Is a self-starter
Expresses thoughts clearly
Enjoys a flexible environment
Demonstrates language development
Demonstrates small motor control and coordination
Demonstrates large motor control and coordination
Demonstrates speech development (articulation)

Please comment on the parents' support of the child's learning and their cooperation with the school: *

We welcome any other information which you believe would be helpful:

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