"*" indicates required fields 1Participant Information2Tutoring Program3B.E.S.T. Program4SOAR Program5Tilly’s Tales6Release of Information LDACK operates in compliance with the Personal Information Protection and Electronic Documents Act (PIPEDA) and we will only use this information collected for the purpose it was collected for. ** Note: A non-refundable down payment (cheque, cash or e-transfer to LDACK@netrover.com) must be made at time of registration. If the Association does not run a session due to insufficient enrollment the down payment will be returned.Participant InformationStudent's Name* First Last Student's Date of Birth* MM slash DD slash YYYY Student's Age*Student's Present Grade* Guardians*Name (First and Last)Home PhoneCell Phone Add RemoveYour Email Address* Emergency Contact Name* In Case of Emergency, and if parents cannot be reached:Emergency Contact Phone*Health Card # In case of medical emergencyMedication On MedicationList of medications Allergies Has allergiesList of allergies Child has problems with: Hearing Speech Sight Other (Please specify) Other EducationSchool Teacher Principal Resource Teacher Testing Previous testing was doneTesting Date MM slash DD slash YYYY Testing Performed By Referral Source School Friend Radio Ad Other If doctor, choose other and enter their namePrograms*Please select the programs you would like to sign up for. Tutoring Program B.E.S.T. Social Skills SOAR (SOme Assembly Required) Tutoring ProgramTutoring Term* Fall (September to January) Winter-Spring (February to June) Summer session #1 (July 8-18) Summer session #2 (July 22-August 1) Summer session #3 (August 12-22) Summer Times* 8:30am – 11:30am 12:30pm – 3:30pm Within each group, select the subjects you want your child to work on. Do not include areas that DO NOT apply to your child. This information will be used to assist staff in setting an individualized program.Main Priorities* Reading Spelling Writing Mathematics Other Secondary Priorities Organization / Study Skills Penmanship (Cursive) Printing Typing Other Main Priorities Subject PriorityWhich of the subjects do you want us to focus on most? Homework*How much time should be allotted for homework? Full Hour Half Hour 15 Minutes My child will not bring homework Challenging TasksHow does your child react to challenging tasks (i.e. withdrawal, aggression, refusal, avoidance)? Additional CommentsStaff will contact you regarding a placement test for your child. This is an informal test to inform us about your child’s specific abilities and needs. B.E.S.T. Social SkillsBetter Emotional and Social TimesB.E.S.T. Program Scheduling* Fall Winter / Spring Summer Problem Areas*Select your child’s top 5 problem areas Accepting Consequences/Accepting No Anxiety – Signs and Symptoms Apologizing Body Language /Body Cues Bullying/Cyber bullying Dealing With Anger and Managing Emotions Depression/Negative Thoughts Empathy Following Instructions Friendship and Support Networks Ignoring Distractions Joining In Keeping out of Fights Listening and Conversation Manners and Giving a Compliment Mindfulness Peer Pressure/Avoiding Trouble Playing a Game/Sportsmanship Relaxation and Coping Strategies Responding to Teasing and Embarrassment Safety/Internet and Social media Self-Esteem/Positive Self-Talk Using Self-Control Using Your Time Wanting Something That Isn’t Mine When You Fail Other Other Problem Areas* Additional Comments SOAR (SOme Assembly Required)Secondary School PreparationThe student has:Check all that apply An IEP Psychological Assessment Identified LD Additional Comments Release of InformationI hereby authorize the Learning Disabilities Association of Chatham-Kent to release information to the following sources regarding my child’s involvement in the program(s) and/or obtain information from the following sources as they deem proper relating to my child’s involvement in the program(s) registered for:School Doctor Agency Other Please enter names separated by commasRelevant DocumentsPlease contact our office to arrange a time to drop off relevant documents or you may upload them here if you have digital copies. Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 2 MB, Max. files: 5. Consent* I have answered the questions on this form and declare the information to be true to the best of my knowledge.Consent for PhotographsI give permission for LDACK to take photos and videos of my child for promotional and marketing purposes On social media On the LDACK website In email correspondence to enrolled families (for group photos/videos) Your Signature*Date of Signing* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
