Academic Coaching Program Application Form

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'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 the 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

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? Please provide as much information as you are comfortable with; this will help us match your student with one of our tutors.*

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? **

YesNo

Student's Current School Placement:*

Regular ClassRegular Class with Withdrawal SupportSelf-Contained Class

Please share as much information as possible. Such as what classes and skills you are needing help with.

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.

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 the tutors we ask families to commit to attending each session of the program they register for and all scheduled sessions. If you will be unable to attend a session, you must inform the program tutor within 24 hours of the scheduled session or the session may be forfeited depending upon the circumstance.

3 For the program to be effective and out of respect for the tutors we ask families to commit to attending all 10 sessions within a 16 week time frame; unless otherwise discussed with the Center Director.

4. For the safety of the staff and other participants, LDAOttawa has the right and responsibility to take actions such as notifying the parent or guardian of issues as well as possible dismissal from the program if a child exhibits continual inappropriate behaviour.

I have read and hereby accept the above waivers and conditions of enrolment and give the LDAOttawa permission to share my child’s information with the appropriate staff and tutors.I have read and hereby accept the above statements of attending and completing all 10 sessions in a timely manner of 16 weeks, unless other arrangements have already been made with the Center Director.

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 Enrolment in Academic Coaching Program: