"*" indicates required fields 1Participant Information2Tutoring Program3B.E.S.T. Program4Elevate (executive functioning)5Release 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 info@ldack.org) 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 RemoveAddress* Street Address Address Line 2 City Province Postal Code Your Email Address* Emergency Contact Name*In Case of Emergency, and if parents cannot be reached:Emergency Contact Phone*Medication On MedicationList of medicationsAllergies Has allergiesList of allergiesChild has difficulties with: Hearing Speech Sight Other (Please specify) OtherEducationSchoolTeacherPrincipalResource TeacherTesting Previous testing was doneTesting Date MM slash DD slash YYYY Testing Performed ByReferral 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 Elevate (executive functioning) Tutoring ProgramTutoring Term* Fall (September to January) Winter-Spring (February to June) Summer Session #1 (July 6-17, 2026) Summer Session #2 (July 20-31, 2026) Summer Session #3 (August 10-21, 2026) Summer Times* 8:30am – 11:30am 12:30pm – 3:30pm Fall/Winter Days* Monday and Wednesday Tuesday and Thursday 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 Study Skills Penmanship (Cursive) Printing Typing Other Main PrioritiesSubject PriorityWhich of the subjects do you want us to focus on most?Homework*Children attending tutoring through the school year can receive help with 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 (July 20-31, 2026) Problem Areas*Select between 1 and 5 choices. 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 Select up to 5 problem areas.Other Problem Areas Not Listed AboveAdditional Comments ElevateIndividual StrengthsBriefly describe your child’s strengths (i.e., creativity, friendship, thinking “outside the box”, etc.)Areas of difficulty* Time Management Task initiation Long-range planning Prioritizing Organization Decision-making Sustained attention Emotional regulation Response inhibition Self-discipline Flexibility (resiliency) Select your child’s problem areas.Identifications Learning Disability ADHD Giftedness Other Please select if your child has been identified with any of the above. Specify other identification/diagnosisAdditional information you’d like us to know about your child: 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:SchoolDoctorAgencyOtherPlease 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. Documents can include IEP, report cards, assessments, etc. 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) attached to reports submitted to our funders Would you like your child to attend full-day camp in collaboration with the Boys and Girls Club of C-K? Yes No If yes, please also fill out the registration form on the BGC of C-K website. Your Signature*Date of Signing* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
