Home
Programs
Contact Us
FAQ
Our Staff
History
Perry County Community Task Force
Helping today's youth become tomorrow's leaders
Grade:
*
Click Here
School:
*
Relationship to Child:
*
Food Allergies:
Date
*
Behavioral Problems:
Lack of Self-Control (inappropriate talk or behavior)
Agression
Phone #:
*
Person Filling Out Checklist:
*
Social Concerns:
Difficulty Getting Along with Others
Wants to be Alone Most of the Time
Low Self-Esteem
Repeated Absences:
Frequently Ill
Unexcused Absences
Additional Information on Child's Needs
Thank you for contacting us! If needed, you will hear back within 48-72 hours.
For a Printable form please click here:
Checklist of Needs
Child's Name:
*
Out of School Characteristics:
In Personal Crisis Situation
Other stresses (family difficulties, peer pressure, chemical dependency concerns, etc.)
Parent's/Guardian's Name:
*
Academic Problem:
Specific Subject
Organizational Skills
Doesn't Turn in Work
View on Mobile