Independence House Academy
Application Form
Student Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Place of Birth
Gender
Male
Female
Nonbinary
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian's Information
Parent/Guardian's Name - Primary
First Name
Last Name
Occupation
Phone Number
Please enter a valid phone number.
Parent/Guardian's Name - Secondary
First Name
Last Name
Occupation
Phone Number
Please enter a valid phone number.
In case of emergency, who will be notified? Please answer the fields below:
Emergency Contact Person
First Name
Last Name
Emergency Phone Number
Please enter a valid phone number.
File Upload
Please upload the following: I EP or 504 plan, Behavioural support plan, Previous Records from past programs or any documents that you believe will support the application.
Upload
Health History
Allergies:
Food allergies
Enviornmental
Medication
Other
If the student have any allergies, please list them down below:
Was the student previously hospitalized or undergo any surgery?
Does the applicant have any medical needs requiring regular attention?
Yes, please provide details below
No
Medication Administration Table:
Rows
Medication name
Dosage
Frequency
Reason
Administration method
Physican
please complete all
I
H
A
.
.
.
Does the student have any medical conditions that you would like to declare?
Immunization/Vaccination
Rows
Vaccinated?
Year
BCG
Yes
No
Hepatitis B
Yes
No
Pneumococcal
Yes
No
HPV
Yes
No
Varicella
Yes
No
Tetanus
Yes
No
Meningitis
Yes
No
Measles
Yes
No
Mumps
Yes
No
Rubella
Yes
No
Disability and Support Needs.
Please list primary and secondary diagnosis:
Communication needs:
Please Select
Verbal
Non-Verbal (eg. uses communication devices)
Sign Language
Other
If other, please explain in the text box at the end of the application.
Mobility Needs:
Please Select
Independent
Requires Support (eg, walker, wheelchair user)
Other:
If other please fill in the box at the end of application.
Does the applicant:
Self-administer medication
No, needs support with medications
Daily living skills: Level of Independence
Fully Indepedent
Requires minimal supervision
Requires significant assistance
Personal Care: Please give details on level of support the applicant requires:
Meal Preparation and Eating
Fully Independent
Needs guidance or supervision
Requires staff to prepare meals
Financial Management: How Independent is the applicant with managing money?
Fully Independent (can budget, shop and make purchases)
Needs some support( Reminders, assistance with budgeting)
Requires full support (e.g. staff handles all money)
Community Integration- Can the applicant participate in community activities?
Yes, Independently
With staff support
No, prefers staying at home
Type option 4
What are the applicants' primary goals for joining the program?
What specific skills would the applicant like to work on?
How can the program support the applicant's long-term goals?
Behavioral Information
Does this applicant display any behaviours that may require support? Tick all that may apply.
Physical aggression, e.g. hitting, pushing, throwing objects
Verbal aggression e.g. yelling, swearing, threats
Self-Injurious behaviours e.g. bitting, hitting self etc
Elopement- running away, wandering off
Noncompliance/defiance
Sensory seeking behaviors, loud noises, repetitive movements
Social Anxiety or withdrawel
N.A
Triggers and Antecedents- Are there specific situations, environments or events that commonly trigger the behaviors?
What level of support does your student currently have? Such as 1:1 etc.
If there is anything you would like to add to your students application, please include it below.
Date Signed
-
Month
-
Day
Year
Date
Applicants Signature
Parent/Guardian Signature
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