Program Application for Reading Rocks - Spring '20 NORWELL DSS

To apply for this LDA Wellington County program please fully complete form below

PLEASE NOTE: This information will be kept strictly confidential. It will only be shared with our staff and program facilitators/volunteers.

This program begins on Sept. 28, 2021 and runs Tuesday and Thursday from 6:00-7:00 pm, for a total of 8 weeks.

*ACCEPTANCE INTO THE PROGRAM DEPENDS ON AVAILABILITY OF VOLUNTEER TUTORS. YOU WILL BE NOTIFIED IF YOUR CHILD HAS BEEN ACCEPTED NO LATER THAN SEPT. 14, 2021.

Please note that our main correspondence is via email; please ensure you provide the most current email address at all times.

* required

Please indicate your relation to the child: *

Mother Father Guardian

Your Name *

First Name Last Name

Your E-mail Address *

Phone Number. (Please provide the number we could reach you at in the hours before and during program times) *

Area Code Phone Number

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Person(s) Available During Online Program to Support if Needed *

Mother Father Other

Please check: *

Non-LDA Member Current LDA Member

Child's First and Last Name: *

First Name Last Name

Age: *

Current School Grade: *

Are there any medical or behavioral issues that we need to be aware of? Please specify *

Has your child been referred to this program by their school? *

Yes No

Has your child ever received tutoring or support for their reading skills? *

Yes No

Program sessions will be running online. *Does your child have access to reliable high-speed internet, a computer/laptop with built-in speakers, a microphone and webcam? *

Yes No

If your child has a formal diagnosis of a Learning Disability, please list, including who made the diagnosis and when. *

If your child has been diagnosed with other execptionalities (i.e. ADHD, OCD, Autism, Intellectual Disability), please list, including who made the diagnosis and when *

Specify what areas your child struggles with because of their Learning Disability/difficulty (i.e. Reading difficulties, Memory, Social Skills, etc.)? (even if they don't have a specific diagnosis) *

What are your child's strengths in relation to their learning difficulties? *

Please list your child's special interests, abilities, hobbies, sports? *we use this information to help match you child to a tutor with similar interests *

Is there any additional information you would like us to know about your child?

Reading: *

Spelling: *

Writing: *

Math: *

Is your child currently on an IEP? *

Yes No

Student's Current School Placement *

Regular class Regular with withdrawal support Self-contained class

1. The parent or guardian of the above-named participant, releases the LDAWC, its directors, staff, agents and members from any loss, personal injury, accident, misfortune or damage to the above-named or his/her property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the above-named participant.

2. For the program to be effective and out of respect for volunteers we ask families to commit to attending each session of the program they register for. If you will be unable to attend a session, you must inform tutor and program facilitator with as much notice as possible.

3. For the safety of the volunteer staff and other participants, LDAWC has the right and responsibility to take actions such as phone calls home and possible dismissal from program if a child exhibits continual inappropriate behaviour.

4. I understand that if my child’s volunteer tutor withdraws from the program, my child may be placed with an alternate volunteer tutor if one is available.

I have read and hereby accept the above waivers and conditions of enrollment and give the LDAWC permission to share my child’s information with the appropriate staff and program volunteers.

Program Application for Reading Rocks ONLINE (T/T 6:00-7:00pm) Fall '21

Child Information

Student Profile

Academic Level

Waivers and Conditions of Enrollment in Reading Rocks Program: