"*" indicates required fields The information collected in this form will be kept strictly confidential. It will only be shared with those who are involved in the planning and delivery of the program.What Niagara Catholic elementary school does your child attend?* By applying for this program, you understand that the program takes place on Tuesday and Thursday evenings from 6:00-7:00 pm and that it will be your responsibility to arrange for your child's transportation to and from the program.* I will ensure my child has transportation to and from the program. Primary Contact InformationThe primary contact is the individual completing this application with whom the LDANR will communicate regarding the application.Primary Contact Name* First Name Last Name Primary Contact Email*Please note, the LDANR’s primary form of communication is through email. Primary Contact Phone Number*Student InformationThe student is the individual to whom this application applies.Student Name* First Last Student Grade*Please note, to participate in this program, the student must be in Grades 2, 3, or 4. Grade 2 Grade 3 Grade 4 Does the student have a formal diagnosis of a learning disability?*i.e. reading disability (dyslexia), math disability (dyscalculia), writing disability(dysgraphia). If unsure, please visit the LDANR website for the definition of a learning disability. Yes No I don’t know Note: To be accepted into the program, the applicant does not need to be formally diagnosed or identified with a learning disability, but must display characteristics of having a suspected learning disability.Is the student diagnosed with other exceptionalities?*(i.e. AD(H)D, OCD, Autism, Auditory Processing Disorder, Intellectual Disability) Yes No Please list all exceptionalities.*How does the student function in a group setting?*i.e. better one-to-one, is shy in a group etc.What would you like the staff working with the student to know about them?*Supporting DocumentsTo determine your child’s need for the program, we must receive a copy of your child’s most recent report card along with your application.Report CardPlease upload your child’s most recent report card, or you may email this to the appropriate Program Coordinator.Max. file size: 20 MB.Waivers and Conditions I hereby authorize the administration of any and all emergency medical attention that the student might require as a result of injury or sickness while attending the program. I hereby agree to comply with the LDANR’s policies on anti-discrimination, violence and harassment. This is with the understanding that non-compliance may result in removal from program. I hereby release the LDANR, its directors, staff, agents and members from any loss, personal injury, accident, misfortune or damage to the student or their property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the applicant. I understand that the information collected on this form will only be used to assess the applicant’s eligibility for the program. This information will only be shared with staff involved in the planning and delivery of the program. I understand that for the program to be effective, and out of respect for the program staff and those who do not get a spot in the program, I will do my best to ensure the student attends the program. I understand that for the safety of the staff and students, LDANR has the right and responsibility to take actions such as phone calls home and possible removal from program if a student exhibits inappropriate behaviour. I understand that, for the program to run, enough eligible students must apply for the program. If there is low enrolment, the LDANR has the right to cancel the program at any time. I understand that data is collected by the LDANR from the program to be used when reporting to funders/sponsors. All information used for reporting purposes is kept confidential and only used by LDANR staff. Student names are removed and student data is kept anonymous. Possible data sources used for reporting purposes include survey responses, ages, type of LD diagnosis. If you do not wish for the student’s assessment data to be used for research purposes, please make note in the comment section below, or contact the LDANR office. I have read and hereby accept the above waivers and conditions of enrolment and give the LDANR permission to share the student's information with the appropriate staff who are involved in the planning and delivery of the program.* 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:* Questions or CommentsIf you do not receive a confirmation/thank you message after submitting your application, please contact the office at info@LDANiagara.org as soon as possible to ensure we received it. CAPTCHANameThis field is for validation purposes and should be left unchanged.
