Program Application for Reading Rocks Spring 2024

Program Application for Executive Functioning WINTER 2025
To apply for this LDA Wellington County 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.

Location:

John F Ross, 21 Meyer Dr, Guelph

Duration:

Feburary 3rd - April 7th

6:30pm-7:30 pm

Thursdays (tentative)

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. Our program relies on volunteer tutors, and we work very hard to match their skills with the needs of individual students. However, registering early is one of the factors that we consider when making those decisions.
* required

Please choose a time and date that would work best for your schedule. This will help us in determining the best day to offer the program. *

	1st choice	2nd choice	3rd choice	Not Available
Mondays 6:30-7:30 pm
Tuesdays 6:30-7:30 pm
Wednesdays 6:30-7:30 pm
Thursdays 6:30-7:30 pm
Fridays 6:30-7:30 pm

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
Person(s) responsible for drop-off and pick-up*

MotherFatherGuardianOther
Other person(s) name and relationship, responsible for drop-off and pick-up
Please check:*

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

First Name (Given Name)Last Name (Family 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? *

YesNo
Has your child participated in the EF Program before?*

YesNo
If yes, when was the last session attended
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.*
If your child has been diagnosed with other exceptionalities (i.e. ADHD, OCD, Autism, Intellectual Disability), please list.*
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 help match you child to a tutor with similar interests*
Is there any additional information you would like us to know about your child?
Is your child currently on an IEP?*

YesNo
Student's Current School Placement*

Regular classRegular with withdrawal supportSelf-contained class
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.
Should be Empty:

Program Application for Executive Functioning WINTER 2025

Child Information

Student Profile

Waivers and Conditions of Enrollment in Executive Skills Program: