The program will run on Tuesdays and Thursdays from 3:10pm 4:10pm at the High

School/Middle School Building. Targeted Services Program will begin November 17th and
end April 7th.

Intake/Continual Learning Plan

Student Name:_____________________________Grade:__________
School: Zumbrota-Mazeppa Middle School

Date Referred: Fall, 2015_________

Parent/Student Goals: Please indicate your area of concern(s) for you

son/daughter:
____Improve reading, writing, math skills
decisions
____Decrease stress/anxiety
Attendance
____Increase motivation/attitude
conflicts with others
____Learn more about oneself
esteem
____Discover/enhance individual talents
amount of reading at home

____Make better
____Improve
____Decrease
____Increase self____Increase

____I give my son/daughter permission to participate in the Targeted Services Program on

Tuesdays and Thursdays
from 3:10pm -4:10pm throughout the 2015-2016 School year.
____I decline the opportunity for my son/daughter to participate in the Targeted Services
Program.

________________________
Parent Signature

_________________________
Date

________________________
Targeted Services Administrator

_________________________
Date