Program Application for Reading Rocks Spring 2024

Program Application for Executive Skills FALL 2025
Welcome!
We're so glad you're interested in our programs. Our goal is to provide safe, supportive, and meaningful learning opportunities for children and youth with diagnosed or suspected learning disabilities (LDs) and ADHD.

Please Note:
Our programs are specifically designed for participants with a suspected or diagnosed LD and/or ADHD, and are not structured for individuals with an intellectual disability diagnosis or those requiring significant behavioural support. While other exceptionalities, such as Autism or Mild Intellectual Disability, can also affect learning, a learning disability is a distinct diagnosis.

To learn more about what qualifies as a learning disability, please visit: https://www.ldao.ca/introduction-to-ldsadhd/what-are-lds/
Program Details

Location:

John Galt Public School (50 Laurine Ave, Guelph, ON)

Duration:

October 6 to December 5

6:30pm-7:30pm

In person - Thursdays

Online - Thursdays

**This year we will have options to participate completely online or completely in person (switching formats mid-program won’t be possible).

Our main correspondence is via email; please ensure you provide the most current email address at all times.

PLEASE NOTE: Acceptance into the program is NOT first come/first served. We take great care to review each application to make sure our program is the right fit for your child.

To apply for this LDAWC program, please fully complete the form below (even if you've provided this information in a prevous application).

This information will be kept strictly confidential. It will only be shared with our staff and program facilitators/volunteers.
* required
Please indicate your relation to the child:*

MotherFatherGuardianOther
Your Name*

First Name (Given Name)Last Name (Family 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 CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person(s) responsible for drop-off and pick-up*

MotherFatherGuardianOther
Other person(s) name and relationship, responsible for drop-off and pick-up
Are you applying for the in person or online Program?*

In personOnline
Are you able to commit to bringing your child to the program every Thursday for the duration of the program?*

YesNoNot sure
Please check:*

Non-LDA MemberCurrent LDA Member
Student Information
Child's First and Last Name:*

First Name (Given Name)Last Name (Family Name)
Age: *
Current School Grade Level:*
What school board does your child belong to?*
Does your child have a formal learning disability diagnosis? [please note if they don't that it does not exclude them from the program]*

YesNo
If your child has been diagnosed with a learning disability, please specify: *
Is your child diagnosed with other exceptionalities? This includes autism, intellectual disabilities, down syndrome, etc.*

YesNo
If your child has been diagnosed with another exceptionality, please specify: *
Has your child been referred to this program by their school? *

YesNo
Is your child currently on an IEP?*

YesNo
Student's Current School Placement*

Regular classRegular with withdrawal supportSelf-contained class
Has your child participated in the Executive Skills Program before?*

YesNo
If yes, when was the last session attended
Behavioural-Related Question

Please provide as much detailed information as possible to assist with screening.
Does your child have difficulty working with others?*

YesNo
Does your child have difficulty following verbal directions well?*

YesNo
Does your child display physical aggression?*

YesNo
Does your child display verbal aggression?*

YesNo
Does your child have a tendency to flee?*

YesNo
If you indicated that your child has any behavioural concerns as noted above, please elaborate on them in the space provided*
If there is any other information you think would be beneficial for our staff and volunteers to know about your child, should they be accepted in the program?*
Student Profile

Please provide as much detailed information as possible to assist with screening.
Please specify what your child would like to get out of this program? *
What are your child's strengths in relation to their executive functioning?*
What would they like to work on in relation to their executive functioning?*
Please list your child's special interests, abilities, hobbies, sports? *we use this information to make the program more relatable and enjoyable for the students*
Is there any additional information you would like us to know about your child?
Waivers and Conditions of Enrollment in Executive Skills Program:
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 tutors 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 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 mentor withdraws from the program, my child may be placed with an alternate 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.

By signing below, I agree that:

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.

I agree to the terms and conditions of the LDAWC program I am applying for and I attest to the accuracy of the information included in this application form, and that I am submitting this form securely via Jotform and agree to Jotform terms and conditions.
Signature*

Clear
Please upload your child's most up to date report card (dated within the past year)

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Please upload your child's IEP (if you have one)

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Any additional documentation you think you be appropriate

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Should be Empty:

Program Application for Executive Skills FALL 2025

Student Information

Behavioural-Related Question

Student Profile

Waivers and Conditions of Enrollment in Executive Skills Program: