Student Profile - ATAYOKAN Program
Form to be completed by Indigenous Education staff.
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Thank you for filling out this brief profile. This information is for the instructor only. This information will help ensure that any challenges with students can be addressed appropriately and behaviours dealt with in the context of the young persons' life experience.
Name of Student
*
First Name
Last Name
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Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other Preferred Identifier
Grade
*
School / Program
*
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Reason for Referral:
Please give a brief description of the following:
School Success:
*
Peer Interactions:
*
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Reaction to stress or new situations:
*
Any diagnosis/other information that would be helpful for us to know:
*
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Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Information provided by:
*
Email
*
example@example.com
Signature
*
You must continue to the next page and select the blue box that says 'Sign Document' to submit document.
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Should be Empty: