Executive Functioning Program Application Form

Application for Executive Functioning Program

To apply for this LDAO-C program please fully complete form below. This information will be kept strictly confidential, and will only be shared with our staff and program facilitators/volunteers.
Executive Function is the management system of the brain. It includes skills such as working memory, flexible thinking, and impulse control. Many students with learning disabilities have poor executive functioning skills as a result might struggle with goal setting, making a plan, and getting things done. Focusing, following directions, and controlling their emotions can also be a challenge.

Our 8-week program is offered in a small-group setting. Students will have the opportunity to set goals for themselves, and learn the skills they need to successfully complete school assignments and projects.

Dates and Times: Thursdays from 6:30 - 7:30 pm, starting January 16

Location: LDAO-C Learning Centre (1547 Merivale Road, Suite 450)

Skill Development and Practice Areas: organization, study skills, motivation, planning

Cost: $250.00

Email jade@ldaottawa.com for more info
Parent/Guardian Contact and Membership Information
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
Are you a member with the LDAO-C?*

I am a current LDAO-C member?I am not an LDAO-C member?I am not sure whether I am an LDAO-C member. Please check for me.
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 2024/25 School Year*
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
Waivers and Conditions of Enrollment in Executive Functioning Program:
1. The parent or guardian of the above-named participant, releases the LDAO-C, 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, the LDAO-C 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 LDAO-C permission to share my child’s information with the appropriate staff and program volunteers.
Should be Empty:

Application for Executive Functioning Program

Parent/Guardian Contact and Membership Information

Child Information

Student Profile

Academic Level

Waivers and Conditions of Enrollment in Executive Functioning Program: