Step 1 of 8 12% *****PLEASE NOTE: The LDANR has made the decision to keep all Spring programming online to ensure the safety of our clients, staff, and volunteers at this time. While we understand that in-person services are often preferred, we are working to provide services that can continue to promote growth and learning during these unprecedented times. *****To apply for an LDANR program, please complete the following steps: Fully complete Steps 1-8 of the Program Application Form and click submit (please note: you cannot save). Submit supporting documents. The application is NOT CONSIDERED COMPLETE until your child's most recent report card/progress report has been received. Supporting documentation may include: - most recent report card OR progress report (*required); - Individual Education Plan (*required, if applicable); - Assessments (if applicable); - Teacher Feedback Form (if possible - Click Here for the Teacher Feedback Form); - 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, program payment will be required. This will be outlined in the acceptance email. Subsidy and payment plans may be available. Please note: This information will be kept strictly confidential. It will only be shared with LDANR staff and volunteers who will be working with the children. LDANR programs are designed for individuals with learning disabilities, not other exceptionalities. If unsure of eligibility, contact the office prior to completing the form at info@Ldaniagara.org.Member Status*Non-MemberCurrent MemberHas your child participated in LDANR programming previously?*YesNoProgram*Month/Year*How did you hear about LDANR?* Flyer/Brochure Friend/Family Member LDANR Communication (email, website, etc.) Your School/Teacher Other Please specify:Participant's Name* First Last Birth Date (dd/mm/yyyy)* Date Format: DD slash MM slash YYYY Age*Grade*School Board*Niagara Catholic (NCDSB)Niagara Public (DSBN)Mon AvenirPrivate SchoolHomeschoolOtherPlease Specify:*SchoolCaregiver's Name* First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Please provide a phone number of where the caregiver(s) can be reached during the program sessions.Caregiver 1 (Primary Phone)*Caregiver 1 (Secondary Phone)Caregiver 2 (Primary Phone)Caregiver 2 (Secondary Phone)**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*(other than those listed above)Emergency Contact - Phone*Emergency Contact 2 - NameEmergency Contact 2 - Phone Does your child have a formal diagnosis of a learning disability? (i.e. reading disability (dyslexia), math disability (dyscalculia), writing disability(dysgraphia))*Please visit the website for the definition of a learning disability.YesNoI don't knowType of LD:Who made the diagnosis?When?Note: To be accepted into the program your child does not have to be formally diagnosed or identified with a learning disability, but must show signs of having a suspected learning disability.Is your child diagnosed with other exceptionalities?*(i.e. AD(H)D, OCD, Autism, Auditory Processing Disorder, Intellectual Disability)YesNoPlease 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, regardless of if they 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 tasks?*YesNoHow does your child function in a group (i.e. size of group)?*Please identify any behavioural issues the LDANR should be aware of:Physical Aggression*(i.e. hitting/kicking/biting)YesNoPlease provide further detail:Verbal Aggression*(i.e. swearing/insulting others/disrespectful language)YesNoPlease provide further detail:Defiant Behaviours*(i.e. refusals to participate/transition)YesNoPlease provide further detail:Tendency to Flee*(i.e. run/escape when frustrated/upset)YesNoPlease provide further detail:Other than those behaviours listed above, if your child displays other forms of behaviour issues, please list them in the space provided:**Refunds will NOT be provided if your child is removed from a program due to misconduct.Does your child follow verbal directions well?*YesNoDoes your child follow written directions well?*YesNoDo you believe your child would be able to engage in an online learning environment (i.e., remain focused, follow instructions given)?*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? Academic Level (MUST provide grade level of performance; if unsure ask child’s teacher)Reading*Spelling*Writing*Math*Is your child currently on an Individual Education Plan (IEP)? (If yes, please attach a copy of the IEP with other supporting documents to this form or email upon completion)*YesNoPresent Placement:*Regular ClassRegular Withdrawl SupportSpecial ClassDoes your child have any allergies or nutritional alerts that we should know about?*YesNoPlease specify:*Does your child have any SEVERE allergies that require an Epipen?*YesNoPlease specify:*Does 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 your program preference from the list below:*Online B.E.S.T. Program (Grades 3-5)Online Reading Rocks Program (Grades 1-8)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:* Mondays & Wednesdays Tuesdays & Thursdays Wednesdays only (*B.E.S.T. Program Only*) Are you familiar with the Microsoft Teams platform?*The LDANR uses Microsoft Teams as our online program platform. If accepted into the program, we will use this information to identify families who may require additional support accessing the platform.YesNoSomewhatPlease confirm that you would like your child to participate in this opportunity by carefully reading and agreeing to the statements of understanding below: I acknowledge that this is an online learning program and my child may require my assistance to navigate this learning experience. I confirm that my child will have access to a working device (i.e. computer, tablet) with microphone, camera, and internet connectivity. Waivers and Conditions of Enrollment: 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 LDANR programs. I hereby agree to comply with the LDANR's policy on anti-discrimination, 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 LDANR, 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 LDANR 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 and volunteers. I understand that for the program to be effective, and out of respect for the program volunteers and those who did not get a spot in the program, LDANR requests that families 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. I understand that 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. I understand that the LDANR charges a fee for our programs, which must be paid prior to the program start date. For more information on program fees, please visit the program-specific pages on the LDANR website. If families require financial aid to access the program, families may apply for subsidy by filling out a Program Subsidy Application Form. I understand that for a program to run, enough eligible participants have to apply for the program. If there is low enrolment, the LDANR has the right to cancel any program at any time. I understand that, if the LDANR must cancel a program date due to circumstances outside of their control (e.g., inclement weather), no refunds will be issued. The LDANR will make an effort to reschedule the cancelled session where possible, but there is no guarantee that a cancelled session will be made up. I understand that 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. I understand that any online programming will take place through a third-party, web-based learning platform. LDANR will not be held liable in the event of a privacy or security breach related to the third-party. Payment instructions:Prior to making any payments, please wait to receive notice of your child's acceptance into the program you've applied for. With the temporary closure of the LDANR's physical office due to COVID-19, only payments made via PayPal will be accepted. Cancellation policy:Cancellations must be made at least one week prior to program start in order to receive a partial refund (an administration fee may apply). 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 consent to the LDANR to take photographs and/or videos of my child while at LDANR programs for the purpose of promoting the LDANR's programs.*Promotion may include advertising on the following LDANR platforms: Twitter, Facebook, website, annual report, program pamphlets, newsletter, and PowerPoint presentations. Yes No I give consent to add my email address to any future mailing lists or notifications sent by LDANR and LDAO.*Notifications may include emails with updates/reminders of program application dates, newsletters, and 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' LDANR will only provide you with important program information via phone call.As a non-profit organization, LDANR relies on Bingo funds to keep our program costs low. However, to receive these funds we must have two (2) volunteers attend each assigned Bingo session (1-2 per month).*Please indicate below which Bingo sessions, if any, you would be interested/available to volunteer at:Niagara Falls Bingo (1-2 Wednesdays/year, 3:00 - 5:30 pm)St. Catharines Bingo (1-2 Sundays/year, 7:30 - 9:30 pm)Those dates/times do not work for me.How else would you support LDANR? (check all that apply) Attend fundraising events Volunteer at fundraising events Sponsoring/Donating to event Social Media Sharing 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 or progress report, Teacher Feedback Form, Individual Education Plan (if applicable), Assessments (if applicable). Please note: Applications are not considered complete until your child's most recent report card or progress report has been received. Drop files here or Teacher Feedback Form Please have your child's teacher complete the Teacher Feedback Form below. This will help LDANR further determine your child's needs for the program.Click Here for the Teacher Feedback FormQuestions or CommentsIf you do not receive a confirmation/thank you message after submitting your application please contact the office at info@Ldaniagara.org to ensure we received it. CAPTCHANameThis field is for validation purposes and should be left unchanged.