Girls Group Application Form

Dates and Times: Wednesdays at 6:30pm (Starts April 30th, runs for 6 weeks)

Location: In-person at our new LDAO-C Learning Centre (1547 Merivale Road, Suite 450)Cost: $250.00

Email bailey@ldaottawa.com for more 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.

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

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 social skills?*

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?*

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

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.

Application for Girls Group

Parent/Guardian Contact and Membership Information

Child Information

Student Profile

Academic Level

Waivers and Conditions of Enrollment in JUMP Math Program: