Step 3. Personal & Developmental Form

Rider's Name *

First Name

Last Name

What DOES the rider know/understand? *

Check all that the rider knows/understands.

Knows numbers

Knows letters

Knows right and left

Describes feeling

Makes choices

Follows 1 step in direction

Follows multi-step direction

Good problem solving

Recognizes name

Knows the word NO

Waves/says hello/goodbye

Shares toys/items

Understands rules

Appropriate touching

Interacts with peers

Appropriate conversation

Makes eye contact

Makes sounds/gestures

Says words

Combines two or more words

Speaks in complete sentences

Understands complex concepts

Sounds out words

Recognizes sight words

Reads sentences

What does the rider NOT know/understand? *

Check all that rider does not know/understand

Knows numbers

Knows letters

Knows right and left

Describes feeling

Makes choices

Follows 1 step in direction

Follows multi-step direction

Good problem solving

Recognizes name

Knows the word NO

Waves/says hello/goodbye

Shares toys/items

Understands rules

Appropriate touching

Interacts with peers

Appropriate conversation

Makes eye contact

Makes sounds/gestures

Says words

Combines two or more words

Speaks in complete sentences

Understands complex concepts

Sounds out words

Recognizes sight words

Reads sentences

What physical skills CAN the rider do: *

Check at that the rider is capable of doing.

Stand on one foot

Hop/Jump

Skip

Weight bearing on hands

Hold object

Release object

Dresses self

Rides a bike

Plays sports

Kick a ball

Catch a ball

Open doors/containers

Use utensils/tools

Manipulates fasteners

Plays on swing

Writes legibly

What physical skills can the rider NOT do: *

Check all that the rider is not capable of doing.

Stand on one foot

Hop/Jump

Skip

Weight bearing on hands

Hold object

Release object

Dresses self

Rides a bike

Plays sports

Kick a ball

Catch a ball

Open doors/containers

Use utensils/tools

Manipulates fasteners

Plays on swing

Writes legibly

Rider communicates: *

verbally

with assistive device

sign language

picture icons

gestures

sounds

Date

MM

DD

YYYY