JUMP Math Program Application Form

Application for JUMP Math Program

To apply for this LDA Ottawa 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.
JUMP Math is an individualized tutoring program for children in Grades 1 to 8 who are performing a minimum of one year behind in the area of math due to a diagnosed, identified, or suspected math disability (dyscalculia) and/or ADHD. Students who are showing signs of math anxiety might also benefit from the program.

Participants work one-to-one with a trained numeracy tutor to build foundational math skills and computational fluency. Sessions are taught using a combination of direct instruction and engaging math games and activities. Participants are also able to set goals and visualize their progress throughout the program in order to foster math confidence.

Dates and Times: various, to be arranged between tutor and student

Location: In-person at our new LDAO-C Learning Centre (1547 Merivale Road, Suite 450) or online, to be arranged between tutor and student

Skill Development and Practice Areas: numeracy, problem solving, critical thinking, logic, reasoning

Cost: $450.00

Email bailey@ldaottawa.com for more information
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
Please provide a phone number that 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.
Service Delivery
Are you applying for in-person (LDAO-C Learning Centre) or online tutoring services?*

In-Person (LDAO-C Learning Centre)Online (Zoom)
As you have selected online tutoring services, who is available during the online session to support if needed?*

MotherFatherOther
Does your child have access to reliable high-speed internet, a computer/laptop with built-in speakers, a microphone and webcam to support the online tutoring session?*

YesNo
Child Information
Child's First and Last Name*

First NameLast Name
Child's Age*
Child's 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 ever received tutoring or support for their math skills?*

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, etc.)? (even if they don't have a specific diagnosis)*
What are your child's strengths in relation to their math difficulties? *
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 where possible.*
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 JUMP Math 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 tutor and 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.

4. I understand that if my child’s volunteer tutor withdraws from the program, my child may be placed with an alternate volunteer tutor if one is available.
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 JUMP Math Program

Parent/Guardian Contact and Membership Information

Service Delivery

Child Information

Student Profile

Academic Level

Waivers and Conditions of Enrollment in JUMP Math Program: