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Initial Guidance Questionnaire for GCC 2018-19

Dear Parent/Guardian:


Because the goal of Greensburg Central Catholic Junior-Senior High is to offer our students the very best education by presenting them with every opportunity to learn, we must ask for our parents’/guardians’ complete cooperation throughout the school year. Individual learning can be a complicated item for students. Providing the school with information regarding prior evaluations, assessments, and/or diagnoses can enhance the learning process.


In the best educational interest of your child, please complete this questionnaire, sign it, and return it with your application materials to the school office. This information will aid us in attempting to assess and meet your child’s learning needs and will be held in strict confidence as regulated by the Diocese of Greensburg Student Records Policy.

Mr. Benjamin Althof, Principal

First Parent/Guardian Name

First Name*

Last Name*
First Parent/Guardian Date of Birth*
I certify that I am 18 years of age or older
First Parent/Guardian Signature*
Second Parent/Guardian Name

First Name*

Last Name*
Second Parent/Guardian Date of Birth*
Third Parent/Guardian Name

First Name*

Last Name*
Third Parent/Guardian Date of Birth*
Fourth Parent/Guardian Name

First Name*

Last Name*
Fourth Parent/Guardian Date of Birth*
Fifth Parent/Guardian Name

First Name*

Last Name*
Fifth Parent/Guardian Date of Birth*
Sixth Parent/Guardian Name

First Name*

Last Name*
Sixth Parent/Guardian Date of Birth*
Seventh Parent/Guardian Name

First Name*

Last Name*
Seventh Parent/Guardian Date of Birth*
Eighth Parent/Guardian Name

First Name*

Last Name*
Eighth Parent/Guardian Date of Birth*
Ninth Parent/Guardian Name

First Name*

Last Name*
Ninth Parent/Guardian Date of Birth*
Tenth Parent/Guardian Name

First Name*

Last Name*
Tenth Parent/Guardian Date of Birth*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Student Information

Full Name *
Grade Entering*

Last School Attended *

Last Date Attended *
Was your child ever evaluated, assessed, tested, or diagnosed with any mental, physical, or emotional condition that could interfere with his/her ability to learn?*
No
Yes
If yes, prior evaluation was completed for any of the following reasons:
Learning
Intelligence
Behavior
Gifted Program
Other (Please explain)

Other
Prior evaluation was completed for one or more of the physical reasons listed below:
Vision
Orthopedic
Hearing
Speech
Development
Other (Please explain)

Other
Prior evaluation was conducted by one or more of the following:
Intermediate Unit
Mental Health
Private Practitioner
School District (Includes early intervention)
Other (Please explain)

Other
Is your child currently identified as requiring special education services?*
No
Yes
If prior evaluation was conducted, would you be willing to provide us with a copy of any report that we feel is necessary for your child's education?*
Yes (Please present a copy to the school.)
No

If "No" was selected, would you be willing to discuss the results with our guidance counselor or principal? Please explain:

My child receives/received the following services. (Please list e.g. speech, remedial reading, gifted, IEP, etc.)
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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