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London, Ontario
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About Dyslexia
Our program
Our program
Enrol
Volunteer
Donate
About us
About us
Events
Announcements
Contact us
Admission application
General Information
Child's Full Name
(Required)
First
Last
Gender
Male
Female
Date and Place of Birth
(Required)
Age in Years
(Required)
and Months
Parent(s) Name(s)
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Telephone
Home
Work
Cell
Email Address
(Required)
School Information
Name of School
(Required)
Grade
(Required)
Has your child received any type of remedial instruction in school?
(Required)
Yes
No
Explain
(Required)
Has the school created an Individual Education Plan (IEP) or similar plan?
(Required)
Yes
No
If yes, please enclose a copy with this application.
Max. file size: 128 MB.
Has a psycho-educational assessment been completed by a registered psychologist?
(Required)
Yes, through the school
Yes, privately
No
Have any other members of the family had learning difficulties?
Father
Mother
Sibling
Explain
(Required)
Describe your child’s learning difficulties
(Required)
Does your child know the alphabet?
(Required)
Yes
No
Can your child printer his/her name?
(Required)
Yes
No
How well do other people understand your child’s speech?
Is English the first language?
(Required)
Yes
No
What language?
(Required)
Is English the child’s primary or main language spoken at home?
Yes
No
Explain
Do you know of any other problems?
(Required)
Yes
No
Explain
(Required)
PHYSICAL HISTORY
Has your child ever been chronically ill?
(Required)
Yes
No
Explain
(Required)
Has your child ever had an extremely high fever?
(Required)
Yes
No
Explain
(Required)
Does your child have any allergies?
(Required)
Yes
No
What allergies?
(Required)
Has your child ever had a severe blow to the head?
(Required)
Yes
No
Is your child currently taking medication?
(Required)
Yes
No
If so, please list
(Required)
Does your child have difficulty hearing
(Required)
Yes
No
Does your child have difficulty seeing?
(Required)
Yes
No
What other relevant medical history should the Centre know about?
BEHAVIOURAL OBSERVATIONS
Observations
Do you have to repeat instructions to your child?
Does your child seem to have difficulty following instructions?
Does your child spend more time than is appropriate on homework?
Does your child need an extraordinary amount of help with homework?
Does your child’s grades in reading, writing, and spelling seem low compared to his/her ability to think and understand?
Does your child talk favourably about school?
Does your child seem to enjoy being read to?
Does your child hesitate to read to you?
Does your child have behavioural problems at school?
This field is hidden when viewing the form
Do you have to repeat instructions to your child?
(Required)
Yes
No
This field is hidden when viewing the form
Does your child seem to have difficulty following instructions?
(Required)
Yes
No
This field is hidden when viewing the form
Does your child spend more time than is appropriate on homework?
(Required)
Yes
No
This field is hidden when viewing the form
Does your child need an extraordinary amount of help with homework?
(Required)
Yes
No
This field is hidden when viewing the form
Does your child’s grades in reading, writing, and spelling seem low compared to his/her ability to think and understand?
(Required)
Yes
No
This field is hidden when viewing the form
Does your child talk favourably about school?
(Required)
Yes
No
How often do you spend time reading with your child? (Times per Week)
This field is hidden when viewing the form
Does your child seem to enjoy being read to?
(Required)
Yes
No
This field is hidden when viewing the form
Does your child hesitate to read to you?
(Required)
Yes
No
This field is hidden when viewing the form
Does your child have behavioural problems at school?
(Required)
Yes
No
Explain
(Required)
Please include all information which might help us to help your child. Use the space below or the back for other relevant information.
How did you hear of us?
Consent
(Required)
The above information is true and accurate to the best of my knowledge. I agree with the planned program to tutor my child using the Orton-Gillingham Approach to remedial tutoring, and will abide by the policies and practices of the Scottish Rite Charitable Foundation Learning Centre Program. I attest that I am (we are) legally responsible for decisions made about this child.