Olympic Educational Service District 114

105 National Avenue North, Bremerton, Washington 98312

(360) 478-6887  1-800-201-1300  FAX (360) 405-5808

BIRTH TO FIVE INDIVIDUAL LEARNING PLAN

Assessment: Fall ☐ Winter ☐ Spring ☐

Child’s Name: Click or tap here to enter text. Date: Click or tap to enter a date.

FAMILY ACCEPTS ☐

By selecting the “FAMILY ACCEPTS” button, you are verifying that you have spoken directly to this family regarding this Individual Learning Plan and the family has agreed to this plan and share information.

Family Name (first and last): Click or tap here to enter text. Staff Name (first and last): Click or tap here to enter text.

Fine Motor: ☐ Gross Motor ☐ Adaptive: ☐ Cognitive: ☐ Communication: ☐ Social: ☐

Goal/Goals for this child/family: Click or tap here to enter text.

School Readiness Goal: (share graph with family and child’s progress) Click or tap here to enter text.

Program Goal: Read to Your Child 20-minutes a Day.

Skills the child will need to accomplish goal/goals: Click or tap here to enter text.

Experiences/activities to help child/family develop and practice skills at home/other: Click or tap here to enter text.

Experiences to help child develop and practice skills in the Classroom, Family Child Care Homes, or Play and Learn Groups: Click or tap here to enter text.

Date Accomplished: Click or tap to enter a date.