Preferred Location *
VYŠKOV

Child's first and last name *

Child's date of birth *

Child's Identification Number:
(e.g., Czech Birth Number / Passport Number / National ID Card Number)

Child's Permanent Address *

School/Kindergarten (Regular Attendance) *

Father's Full Name *

Father's Permanent Address (if different from child's)

Father's Phone Number *

Father's Email Address

Mother's Full Name *

Mother's Permanent Address (if different from child's)

Mother's Phone Number *

Mother's Email Address

Siblings (if any): Please list their full names, ages, and schools attended.

INFORMATION ABOUT THE CHILD

Physical Development
Typical / Age-appropriateAtypical / Delays notedOther

Speech Development
Typical / Age-appropriateAtypical / Delays notedOther

Child's Health Status (Please select all relevant options):
Visual impairment / Vision impairmentHearing impairment / Hearing lossSpeech impediment / Speech disorderChronic illness / Long-term health conditionFrequent illness / Recurrent health issuesRestlessnessHyperactivityAutistic traits / Autism Spectrum Disorder (ASD) characteristicsLearning disabilities / Learning disordersOther

Other Health Impairments / Conditions (Please specify):

Child's Social Competence (Please select all relevant options):
Has friends / Easily makes friendsPrefers to be alone / Has few friendsWell-liked by adultsAccepts authorityFollows established rules

Child's Characteristics Related to Learning / Education (Please select all relevant options):
Completes tasks / Fulfills obligationsIs diligent / Shows effortCooperatesHas various interests / Shows broad interestsShows interest in learning / Is engaged in learningActively seeks new stimuli / Is proactive in seeking knowledgeThe child desires (is interested in) individual education

SERIOUS REASONS FOR INDIVIDUAL EDUCATION

Please state your reasons: *

ENSURING INDIVIDUAL EDUCATION

Legal Guardian's Acknowledgment of Legal Conditions for Individual Education:
YESNO

Estimated Duration of Individual Education From (date):


To (date)

Both Parents (Legal Guardians) Consent to Individual Education:
YESNO

Individual Education Will Be Provided By:
ParentPrivate TutorOther

How Will the Child Maintain Contact with Peers?
Extracurricular activitiesSchool clubOther

Other Way Of Contact With Peers (Please specify):

Primary school providing individualized education

Date of Form Completion:

Name of Completing Legal Guardian: *

Email for Confirmation: *

Parental Declaration: I hereby declare that all the information provided in this questionnaire is true and accurate. I am aware that providing false information may have legal consequences. The information provided in this questionnaire is subject to personal data protection regulations. I consent to the processing of personal data for the purpose of considering individualized education for the period strictly necessary according to school regulations.