Step 1 of 8 12% To apply for an LDANR program please follow these steps: Fully complete Steps 1-8 of the Program Application Form and click submit (please note: you cannot save). Submit the following supporting documents: - most recent report card (required); - Teacher Referral Form (required - Download the Teacher Referral Form); - IEP (if applicable); - Assessments (if applicable); - Any additional information that you feel may be useful in determining your child's needs for the program. Following screening, accepted applicants will be notified closer to the program start date. Following acceptance, membership/program payment will be required (if applicable). This will be discussed during the acceptance phone call/email. If you require financial assistance, please click here to complete and submit a program subsidy application. This information will be kept strictly confidential. It will only be shared with LDANR staff, program staff and volunteers working with children. Please remember these programs are designed for individuals with learning disabilities, not other exceptionalities. If unsure of eligibility, call the office prior to completing the form at 905-641-1021Member Status*Non-MemberCurrent MemberMember Expiration MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberHas your child participated in LDANR programming previously?*YesNoProgram*Month/Year*Participant's Name* First Last Birth Date (dd/mm/yyyy)* Age*Grade*Guardian's Name* First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Please provide a phone number of where the parent and/or guardian can be reached during the program session.Home (Mother)Cell (Mother)Home (Father)Cell (Father)Home (Guardian)*Cell (Guardian)**Please note that our main correspondence is via email; please ensure our agency has the most current email address at all times.Email* Who does the child reside with?*Who has custody of the child?*Doctor's NameDoctor's Phone Number Emergency Contact Name*Emergency Contact Phone*Emergency Contact 2 NameEmergency Contact 2 PhonePerson(s) Dropping Off and Picking Up* Mom Dad Other Name of Mom:*Name of Dad:*Name of Other:*Phone Number of Other*GUARDIANS ARE RESPONSIBLE TO INFORM LDANR IF THEIR CHILD IS GOING TO BE PICKED UP BY A PERSON OTHER THAN THOSE LISTED ABOVE. Please visit resource page for the definition of a learning disability. To be accepted into the program your child does not have to be formally diagnosed with a learning disability but must show signs of having a potential learning disability.Does your child have a formal diagnosis of a learning disability? (i.e. reading disability (dyslexia), math disability (dyscalculia), APD)*YesNoI don't knowType of LD:Who made the diagnosis?When?Is your child diagnosed with other exceptionalities (i.e. AD(H)D, OCD, Autism, Intellectual Disability)? Please list all exceptionalities and dates of diagnosis.*If your child receives any special education support through school what category is your child placed in through the school? If unsure, ask your child’s teacher.Specify what areas your child struggles with because of their learning disability even if they do not have an official diagnosis (i.e. social skills, reading difficulties, math difficulties).* What are your child’s strengths and weaknesses in relation to their learning disability?Strengths*Weaknesses*Does your child tire quickly when completing academic task?*YesNoHow does your child function in a group (i.e. size of group)?*Please identify any behavioural issues LDANR should be aware of (i.e. aggression)*Does your child follow verbal directions well?*YesNoDoes your child follow written directions well?*YesNoDoes your child have any special interests, abilities, hobbies, sports?What embarrasses your child most (i.e. difficulties in group setting)?Is there any additional information you would like us to know about your child? School child is currently attending*Present Grade*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? (If yes, please submit a copy of the IEP with other supporting documents after completing this application)*YesNoPresent Placement:*Regular ClassRegular Withdrawl SupportSpecial ClassDoes your child have any allergies or nutritional alerts?*YesNoPlease list all allergies or nutritional alerts below:*Will your child need to have medication administered during the program? Please note medication will only be administered by LDANR during day programs.*YesNoDoes your child have: Corrective Lenses Hearing Impairment Hearing Aid(s) Has your child participated in: Speech Therapy Visual Therapy Motor Therapy Psychotherapy Program SelectionVisit the program page on the website to read about the program specifics. Please select which program(s) you are applying for:* Reading Rocks (Grades 2 - 10) Reading Rocks Junior (Kindergarten - Grade 1) Let's R.E.A.D (Grades 2 - 4) B.E.S.T. (Ages 6 – 11 years) *NEW* S.M.A.R.T. Math (Grades 2 - 3) Summer S.L.A.M. Program - Sunshine, Learning, Achievement & More! (Ages 6 – 10 years) Please select the location in which you wish to participate. Visit the program page on our website to see what locations the program is currently offered in:* St. Catharines Thorold Welland Fonthill Beamsville Niagara Falls Port Colborne Fort Erie Niagara-on-the-Lake In the event that your location of choice fills up, would you like to be considered for another location?YesNoPlease select all that apply:* St. Catharines Thorold Welland Fonthill Beamsville Niagara Falls Port Colborne Fort Erie Niagara-on-the-Lake Please select the days of the week that you are available for your child to attend program. Check all that apply. Visit the program page on our website to see what days the program is currently offered on:* Monday/Wednesday Tuesday/Thursday Wednesday only (BEST program) Thursday only (BEST program) Full week (SLAM program) Waivers and Conditions of Enrollment: I hereby authorize photographs and/or videotaping to be taken of my child while at the Learning Disabilities Association of Niagara Region for the purpose of promoting the Literacy or Social Skills programs. I hereby authorize the administration of any and all emergency medical attention that my child might require as a result of injury or sickness while attending Learning Disabilities Association of Niagara Region programs. I hereby agree to comply with the Learning Disabilities Association of Niagara Region policy on violence and harassment. This is with the understanding that non-compliance may result in my removal from LDANR programming, thereby requiring a designate to pick-up and drop-off my child. I hereby release the Learning Disabilities Association of Niagara Region, 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. I understand that the information collected on this form will only be used to assess my child's eligibility for programming, to make the Learning Disabilities Association of Niagara Region aware of any medical or allergy concerns for my child, and to ensure safe pick-up and drop-off of my child. This information will only be shared with LDANR staff. For the program to be effective and out of respect for volunteers and spot taken we ask families to commit to attending each session of the program. If attendance is irregular or too many sessions have been missed the participant will be asked to leave the program to open the spot up to another participant. For the safety of the volunteer staff and other participants, LDANR 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. Programs are provided for LDANR members. To participate in Reading Rocks, Reading Rocks Junior, Let's R.E.A.D., B.E.S.T. or S.L.A.M. the individual/family must be members of the Learning Disabilities Association of Niagara Region. An annual LDANR family membership is $50.00. For more information, please see the Membership page at www.LDANiagara.org. Please note, the membership fee does not include the additional program fee (see Program page for program fee information). For a program to run, enough eligible participants have to apply for the program. If there is low enrolment, LDANR has the right to cancel any program at any time. Program promotion may include advertising on the following LDANR platforms: Twitter, Facebook, website, annual report, program pamphlets, newsletter, and powerpoint presentations. External advertisement may include: newspaper or TV Cogeco coverage. If you do not wish to authorize a specific form of advertisement listed above, please make note in the comment section below, or contact the LDANR office. Data is collected from LDANR programs to be used when reporting to funders/sponsors. All information used for reporting purposes is kept confidential and only used by LDANR staff. Participant names are removed and participant data is kept anonymous. Possible data sources used for reporting purposes include test scores, pre and post tests, ages, type of LD diagnosis. If you do not wish for your child's assessment data to be used for research purposes, please make note in the comment section below, or contact the LDANR office. Deadline for applications for all programs is two weeks prior to the start date of the program unless stated otherwise. Payment instructions:Prior to making any payments, please wait to receive notice of your child's acceptance into the program you've applied for. Payments can be made with cash, cheque (payable to Learning Disabilities Association of Niagara Region) or MasterCard/Visa (either online - see Membership page - or by calling the LDANR office). Cancellation policy:Cancellations must be made at least one week prior to program start in order to receive a refund (a $10 administration fee may apply). Cancellation for SLAM must be made two weeks prior to program starting in order to receive the refund. Please note that membership payments cannot be refunded. APPLICATION FORMS THAT ARE INCOMPLETE OR THAT DO NOT HAVE THE RELEVANT SUPPORTING DOCUMENTS WILL NOT BE ACCEPTED.I have read and hereby accept the above waivers and conditions of enrolment and give the LDANR permission to share my child's information with the appropriate staff and program volunteers.* I agree Please type your name in the space below to confirm that you have read and agree to the waivers and conditions of enrolment:*I give the LDANR consent to email me with important program-specific information and details.*YesNo***Please note, by checking 'NO' LDANR will only provide you with important program information via phone call.I give consent to add my email address to any future mailing lists or notifications sent by LDANR and LDAO (i.e. program application dates, newsletters, upcoming events/fundraisers). Please note, you can unsubscribe at any time and other than this communication, LDANR/LDAO will not contact you directly nor give out mailing/email lists to anyone outside the relevant chapter to which they belong.*YesNo***Please note, by checking 'NO' you will not receive notifications of upcoming program application dates or upcoming events.Supporting DocumentsIf you have your child's supporting documents on hand, you can upload them in the space below. If not, the documents can be emailed/scanned to the program coordinator after you have submitted the application.Supporting documents include: Most recent report card, Teacher Referral Form, IEP (if applicable), Assessments (if applicable). Please note: Applications are not considered complete until all supporting documents have been received. Drop files here or Teacher Referral Form Please have your child's teacher complete the Teacher Referral Form below and send it to us. This will help LDANR determine your child's needs for the program.Download the Teacher Referral Form Questions or CommentsIf you do not receive a confirmation/thank you message after submitting your application please contact the office at 905-641-1021 to see if we received it. PhoneThis field is for validation purposes and should be left unchanged.