Academic Coaching Program Application Form

Application for Academic Coaching Program

To apply for this LDA Ottawa program please fully complete form below.
PLEASE NOTE: This information will be kept strictly confidential, and will only be shared with our staff and program facilitators/volunteers.
Please indicate your relationship to the child:*

MotherFatherGuardianOther
Your Name*

First NameLast Name
Your email address*
example@example.com
Phone Number. (Please provide the number we could reach you at in the hours before and during program times) **
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Child Information
Child's First and Last Name*

First NameLast Name
Child's Age*
In which school board is your child's school?*

Ottawa-Carleton District School BoardOttawa Catholic School BoardConseil des écoles publiques de l'Est de l'OntarioOther
Has your child been referred to this program by their school? **

YesNo
What is the name of your child's school?
Child's Expected School Grade for 2022/23 School Year*
Are you applying for in-person (LDAO-C Learning Centre) or online tutoring services?*

Person (LDAO-C Learning Centre)Online (Zoom)
If you selected online: *Does your child have access to reliable high-speed internet, a computer/laptop with built-in speakers, a microphone and webcam? *

YesNo
Student Profile

Please provide as much detailed information as possible to assist with screening.
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 exceptionalities (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, Math, Social Skills, Executive Functioning, etc.)? (even if they don't have a specific diagnosis) **
What are your child's typical behaviours when it come to organizing, planning, studying and motivation?*
What are your child's strengths in relation to their social skills? *
Are there any medical or behavioral issues that we need to be aware of? Please specify **
Does your child have any special interests, abilities, hobbies, sports?*
Is there any additional information you would like us to know about your child?*
Academic Level

MUST provide grade level of performance; if unsure ask child's teacher
Reading:*
Spelling:*
Writing:*
Math:*
Is your child currently on an IEP? **

YesNo
Student's Current School Placement:*

Regular ClassRegular Class with Withdrawal SupportSelf-Contained Class
What does the child need support in?
Please share as much information as possible. Such as what classes and skills you are needing help with.
Availability and Frequency
Please share your availability for sessions; this will help us match your student up faster (ex, weeknights, weekends, specific times). If you desire multiple sessions a week please also note this here.
Waivers and Conditions of Enrollment in Executive Functioning Program:
1. The parent or guardian of the above-named participant, releases LDAOttawa, 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 program facilitator with as much notice as possible.

3. For the safety of the volunteer staff and other participants, LDAOttawa 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.
I have read and hereby accept the above waivers and conditions of enrollment and give the LDAOttawa permission to share my child’s information with the appropriate staff and program volunteers.
Should be Empty:

Application for Academic Coaching Program

Child Information

Student Profile

Academic Level

What does the child need support in?

Availability and Frequency

Waivers and Conditions of Enrollment in Executive Functioning Program: